AHAI Hockey Concussion Reporting Form

Concussion Reporting Form

The USA Hockey Concussion Management Protocol and some state statutes within the Central District, require that an athlete be removed from any training, practice or game if they exhibit any signs, symptoms or behaviors consistent with 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 without restrictions. 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 to return to full sports activities, and send it to the AHAI Player Safety Representative. 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 any 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 Central District Player Safety Coordinator for use in the USA Hockey Player Safety Initiative and for the Central District Player Safety Representative to follow-up with the Association to ensure that all USA Hockey Concussion protocols are being followed.
Player's AHAI Association (No Abbreviations)
Age of Injured Player at Time of Injury*
Playing Age Level *
Date of Injury*

MonthDayYear
Date
Location of Injury: City, State & Arena Name
Name of Person Submitting Form*

First NameLast Name
Submitter's Email*
example@example.com
Submitter's Cell Number

Area CodePhone Number
Date Reported*

MonthDayYear
Date
Should be Empty:

Concussion Reporting Form

Purpose