Concussion Symptom Checklist

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Use this checklist to help evaluate a suspected concussion. This form may be completed by a coach during or after gameplay or practice; or by a parent after a head injury has occurred.

Upon submission of this form, a notification will be sent to the SPYHA Safety Officer. The Safety Officer will follow-up with any further questions and/or instructions.

Email *

Player First Name *

Player Last Name *

Team *

Name of Person Completing Form (first & last) *

Email of Person Completing Form *

Contact Number of Person Completing Form *

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This form was created inside of Sauk Prairie Youth Hockey Association.

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