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CONCUSSION INFORMATION AND SIGNATURE FORM FOR STUDENTATHLETES & PARENTS/LEGAL GUARDIANS (Adapted from CDC Heads Up Concussion in Youth Sports)Public Chapter 148, effective January 1, 2014, requires

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How to fill out concussion statement

01

Obtain the concussion statement form from the appropriate organization or healthcare provider.

02

Read through the form carefully and make sure you understand all the information provided.

03

Fill out your personal information such as name, date of birth, and contact information.

04

Provide details about the concussion incident including when it occurred, how it happened, and any symptoms experienced.

05

Sign and date the form to certify that the information provided is accurate.

06

Submit the completed concussion statement to the required party.

Who needs concussion statement?

01

Athletes who have suffered a concussion during sports activities.

02

Students who have experienced a concussion at school.

03

Individuals who have been involved in accidents resulting in head injuries.

04

Anyone seeking medical treatment for a concussion.

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What is concussion statement?

A concussion statement is a formal documentation that provides information about a potential or actual concussion incident.

Who is required to file concussion statement?

Anyone, such as coaches, athletes, or medical personnel, who witnesses or suspects a concussion incident must file a concussion statement.

How to fill out concussion statement?

To fill out a concussion statement, one must provide details about the incident including date, time, location, individuals involved, symptoms observed, and any actions taken.

What is the purpose of concussion statement?

The purpose of a concussion statement is to document and report any suspected or actual concussion incidents in order to ensure proper care and follow-up for the individuals involved.

What information must be reported on concussion statement?

Information such as date, time, location, individuals involved, symptoms observed, and actions taken must be reported on a concussion statement.

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