Concussion Reporting Form
The USA Hockey/WAHA Concussion Management Protocol and the state statutes require that an athlete be removed from any training, practice or game if they exhibit any signs, symptoms or behaviors consistent with a concussion or are suspected of sustaining a concussion. The player should not return to physical activity until he or she has been evaluated by a qualified medical provider who has provided written clearance to return to sports. Once you hit the Submit button, you will be directed automatically to the USA Hockey Return To Play form. Print it out and have it completely filled out once the player has been cleared and send it to the WAHA Player Safety Coordinator. It is important to know all about concussions and the effects they may have on youth athletes. Once a person suffers a concussion, they are more susceptible to suffering more, especially youth athletes. It is very important that a concussed athlete follow all proper steps and be fully recovered before they return to full participation in athletic activities.
Purpose
This form is used after an athlete has been removed from athletic activity due to a concussion or suspected concussion to report data to the WAHA Player Safety Coordinator for use in the USA Hockey Player Safety Initiative and for the WAHA Player Safety Coordinator to follow-up with the Association to ensure that all USA Hockey/WAHA Concussion protocols are being followed.
Players Association
Region 1
Amery
Ashland
Barron
Burnett
County
Chippewa Falls
Cumberland
Hayward
Rice Lake
River Valley
Spooner
Superior
Region 2
Antigo
Eagle River
Everest
Lakeland Hawks
Marathon County
Marshfield
Medford
Merrill
Mosinee
Price Ice
Rhinelander
South Wood County
Stevens Point
Tomahawk
Region 3
Appleton
De Pere
Fox Valley
Green Bay
Manitowoc
Marinette-Menominee
Jr. Gamblers)
Oshkosh
Shawano
Sheboygan
Waupaca
Region 4
Baraboo
Beloit
Ice Wolves
Janesville
Madison Capitols
McFarland
Middleton
Monroe
Oregon
Patriots
RWD
Sauk Prairie
Skeeters Sled
Stoughton
Sun Prairie
Verona
Polar Caps
Wildcat (Waunakee)
WHOA
Wis. Special Hockey
Region 5
Arrowhead
Beaver Dam
Elmbrook
Fond du Lac
Kenosha
Milwaukee Area
Jr. Admirals
Winter Club
Ozaukee
Pleasant Prairie
S.H.A.W.
Washington County
Waukesha
Waupun
Region 6
Altoona
Black River
Blackhawk (Baldwin)
Chippewa Valley Girls
Clark County
Coulee Region Sled
Eau Claire
Hudson
Menomonie
New Richmond
Onalaska/Holmen Tornado
River City (LaCrosse)
River Falls
Somerset
Sparta
Tomah
Viroqua
West Salem
Miscellaneous Assoc.
WEHL Northeast White
WEHL Northeast Kelly
WEHL North Central
WEHL Southeast Teal
WEHL So. Central Orange
WEHL So. Central Royal
WEHL Southeast Blue
WEHL Western
Team Wisconsin
Summer League Team
Other
Name of Injured Player
First Name
Last Name
Age of Injured Player at Time of Injury
*
Playing Age Level
*
Youth 6U
Youth 8U
Youth 10U
Youth 12U
Youth 14U
Youth 16U
Youth 18U
Girls 6U
Girls 8U
Girls 10U
Girls 12U
Girls 14U
Girls 16U
Girls 19U
High School
Date of Injury
*
-
Month
-
Day
Year
Date
Location of Injury: City, State & Arena Name
Name of Person Submitting Form
*
First Name
Last Name
Submitter's Email
*
example@example.com
Submitter's Cell Number
*
-
Area Code
Phone Number
Date Reported
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: