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Concussion Referral & Clearance Form SECTION 1 DETAILS OF INJURED PERSON (please print clearly) TEAM OFFICIAL TO COMPLETE (Manager, Coach or First Aid / Healthcare practitioner*) AT THE TIME/ON THE

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How to fill out concussion referral and clearance

01

Obtain the concussion referral and clearance form from the appropriate medical professional or institution.

02

Fill out the patient's personal information including name, date of birth, and contact information.

03

Provide details of the concussion diagnosis including the date of injury and symptoms experienced.

04

Include information on any treatment received for the concussion.

05

Have the form signed by the medical professional providing the clearance indicating that the patient is safe to return to activities.

Who needs concussion referral and clearance?

01

Athletes who have suffered a concussion and are seeking clearance to return to sports or physical activities.

02

Individuals who have experienced a concussion and require medical documentation for work or school purposes.

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What is concussion referral and clearance?

Concussion referral and clearance is the process of evaluating and managing individuals who have experienced a concussion to determine if they are safe to return to activities.

Who is required to file concussion referral and clearance?

Healthcare providers, coaches, and school officials are required to file concussion referral and clearance for individuals who have experienced a concussion.

How to fill out concussion referral and clearance?

Concussion referral and clearance forms typically require information such as symptoms, date of injury, medical history, and clearance for return to activities.

What is the purpose of concussion referral and clearance?

The purpose of concussion referral and clearance is to ensure the safety and well-being of individuals who have experienced a concussion before allowing them to return to activities.

What information must be reported on concussion referral and clearance?

Information such as symptoms, date of injury, medical history, and clearance for return to activities must be reported on concussion referral and clearance forms.

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