Concussion Report Form

Concussion Reporting Form
The USA Hockey / Midwest Amateur Hockey Association 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 licensed medical provider who has provided written clearance to return to sports.
This form is to be used after an athlete has been removed from athletic activity due to a suspected concussion to report data to the MWAHA Player Safety Coordinator for use in the USA Hockey Player Safety Initiative.
Name of Injured Player *

First Name Last Name
Age of Injured Player *
Players Age Group Level *
Players Association *
Players Team *
Date of Concussion Injury *

Month Day Year
Date
Description of Concussion Injury (Please provide in detail how concussion occurred) *
Upload Video or Picture (If Available) of the Concussion as it happened.

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Location of Injury: City, State & Arena / Ice Rink Name *
Name of Person Submitting Form *

First Name Last Name
Submitting Person’s Email *
example@example.com
Submitting Person’s Cell Phone Number *

Area Code Phone Number
Date Injury Reported (Today’s Date) *

Month Day Year
Date
Should be Empty:

Concussion Reporting Form