Concussion Reporting FormFields marked with an * are required.error_outline Some fields contain errors Show {{form.showErrors ? 'Less' : 'More'}}keyboard_arrow_down {{error.field}} - {{error.message}} DescriptionComplete this form when you or someone else is suspected of having a concussion. The Health and Safety Committee will receive this report. Thank you.Your NameFirst NameLast NameName of person reporting suspected concussionYour EmailYour contact email in case more information is neededContact EmailPlayers email or parents or guardians email.Athletes NameFirst NameLast NameName of the athlete suspected of sustaining a concussion.Contact Phone NumberPlayers Phone Number or parents or guardians Phone Number.Date of IncidentTime of IncidentDescription of eventsExplain how the player hit their head and what followedSigns and Symptoms Headache Peassure in the head Dizziness Nausea or vomiting Blurred vision Sensitivity to light or sound Ringing in the ears Balance problems Tired or low energy Drowsiness “Don’t feel right” Not thinking clearly Slower thinking Feeling confused Problems concentrating Problems remembering Irritability (easily upset or angered) Depression Sadness Nervous or anxiousCheck off all signs and symptoms the player was exhibiting at the time of the incidentRed Flag Symptoms Neck Pain/Soreness Double Vision Weakness or tingling in arms or legs Severe or increasing headache Loss of Consciousness Seizure or Convulsion Vomiting more then once Increasingly aggitated, restless or aggressive Confusion increasingCheck off all symptoms the player was exhibitingTreatmentDescribe what was done after the player hit their headDid the player go to the hospital Yes they went to the hospital No they went home I am unsurePaymentDiscountSubtotalTaxTotal USDSubmitThank you for reporting a suspected concussion. Your submission has been sent to SMBA's Health and Safety Committee and will be followed up with.
