TMU Suspected Concussion Reporting Form 

Designated person(s) must immediately remove the athlete from further training, practice or competition if the athlete has sustained a concussion or is suspected of having sustained a concussion regardless of whether the concussion or suspected concussion was sustained from an activity associated with TMU. 

In accordance with Rowan's Law and the Competitive Clubs Removal and Return-To-Play Concussion Protocol/Guidelines, the designated person(s) will record all incidents when an athlete is removed from further training, practice or competition because they are suspected of having sustained a concussion. This is regardless of whether the athlete is later diagnosed with a concussion. This form should be completed within 24 hours of incident occurring.

*IMPORTANT* - If there is concern after an injury including whether ANY signs, or symptoms of a concussion as defined by the "The Concussion Recognition Tool 5 (CRT5)" then the player should be safely and immediately be removed from play/game/activity. If no licensed healthcare professional is available, call an ambulance for urgent medical assessment.

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Email *
Athlete's First Name
Athlete's Last Name
Athlete's Email
Designated Person's First Name 
Designated Person's Last Name 
Designated person's email
Designated person's phone number
Date the incident occurred
MM
/
DD
/
YYYY
Time incident occurred
Time
:
Please describe the incident that lead to you to believe in the instance of a concussion.
Please indicate all symptoms (check all that apply)
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