Copy to: Parent and Student Cumulative File www.cdc.gov/Concussion!
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Jordan'School'District'Head'Injury'Reporting'Form'
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Date of Injury:_______________________ Time of Injury: _______________________
Dear Parent or Guardian,
Your child ___________________________________, sustained a witnessed or suspected injury to the head today at school.
____________________________________________________________________________________________________
A. No symptoms observed. None of the symptoms mentioned in section B were witnessed or reported to the school.
Your child was checked! at!the!time!of!the!accident!and!15!and!30!minutes!after!the!injury.!If!yo u!notice!any!of!
the! sym ptoms!listed!below!at!h ome,!call!yo ur!d octor!immediately!and!desc ribe !the!injury!and!symptoms.!
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_________________________________________ _______________
Parent Notified
Signature of principal or designee Date
____________________________________________________________________________________________________
B. Symptoms observed or reported. Your student appeared to be stable, but displayed symptoms of a witnessed or
reported head injury. You have been contacted to transport your child and have been advised to contact your
student’s primary care provider or seek care at the nearest emergency department. The following common signs and
symptoms of concussion were witnessed or reported at school (circle):
Symptoms witnessed by others:
• Student appears dazed or stunned
• Confusion
• Forgets plays
• Unsure about game, score, opponent
• Moves clumsily (altered coordination)
• Balance problems
• Personality change
• Responds slowly to questions
• Forgets events prior to hit
• Forgets events after the hit
Symptoms as reported by student:
• Headache
• Fatigue
• Nausea or vomiting
• Double vision, blurry vision
• Sensitive to light or noise
• Feels sluggish
• Feels “foggy”
• Problems concentrating
• Problems remembering
To return to physical activity at school, you will need to provide a note or a Concussion Return to Play Clearance
Form completed by a trained qualified health care professional.
Parent notified,
________________________________________
student transported
Signature of principal or designee
______________
Date
____________________________________________________________________________________________________
C. Injury required immediate medical attention in accordance with the law.
The following signs and symptoms of
a concussion were witnessed or reported, indicating a deterioration of the student’s condition:
• Student has experienced a witnessed or reported loss of consciousness, of any duration, as a result of a head injury
• Student has demonstrated one or more of the following symptoms (circle):
o Deterioration of neurological function (i.e., headaches, unequal pupils, slurred speech, unable to recognize
people or places, weakness or numbness in arms or legs)
o Decreasing level of consciousness
o Decrease or irregularity in respirations
o Any signs or symptoms of associated injuries, spine or skull fracture, bleeding
o Mental status changes: lethargy, difficulty remaining alert, confusion or agitation, unusual behavior
changes
o Seizure activity
To return to physical activity at school, you will need to provide a note or Concussion Return to Play Clearance
Form completed by a trained qualified health care professional.
Parent notified
___
_____________________________________ ______________
of transport
Signature of principal or designee Date
