Concussion Checklist
Complete this checklist when you suspect a student has a concussion or traumatic head injury, and share it with the health care provider as required.
Note: The student may not resume participation until evaluated by a qualified health care provider trained in concussion management and a written statement is provided to the District. The parent should receive a copy of the completed checklist for the health care provider to review.
Student Name
*
First Name
Last Name
School
*
Please Select
Antimony Elementary
Boulder Elementary
Bryce Valley Elementary
Bryce Valley High
Escalante Elementary
Escalante High
Panguitch Elementary
Panguitch Middle
Panguitch High
Garfield Online
Date and Time of Injury
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Activity or Event When Injury Occurred
*
How Did the Injury Occur?
*
Observed Signs (check all that apply)
*
Appears dazed or stunned
Confused about assignment or position
Forgets instructions
Unsure of game/score/opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood/behavior/personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall
Symptoms Reported by Student (check all that apply)
*
Headache or pressure in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish/hazy/foggy/groggy
Concentration or memory problems
Confusion
Just not feeling right / feeling down
Actions Taken (check all that apply)
*
Student immediately removed from participation
Parent/guardian notified
Referred to qualified health care provider
Documented in student health record
Entered on Student Injury Report website
Staff Member Name
*
First Name
Last Name
Staff Role
*
Staff Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Checklist
Submit Checklist
Should be Empty: