Appendix C- Page 1 of 4
Appendix C Tool to Identify a Suspected Concussion (revised September 2018)
Identification of Suspected Concussion
Following a blow to the head, face or neck, or a blow to the body that transmits a force to the head, a
concussion must be suspected in the presence of any one or more of the signs or symptoms outlined in
the chart below and/or the failure of the Quick Memory Function Assessment.
First, assess the danger to the victim and the rescuer, and then check airway, breathing and
An incident occurred involving ________________________________ (student name) on
______________ (date) at _________ (time).
He/she was observed for signs and symptoms of a concussion.
No signs or symptoms described below were noted at the time of assessing the student/athlete.
Note: Continued monitoring of the student/athlete is important as signs and symptoms of a
concussion may appear hours or days later (refer to Step D).
The following signs were observed or symptoms reported (refer to Step A or Step B).
Red Flags
Call 911. Check for Red Flag sign(s) and or symptom(s).
If any one or more red flag sign(s) or symptom(s) are present, call 911, followed by a call to
parents/guardians/emergency contact. Follow the Risk Management Advisory-Transporting
Students to Hospital/Urgent Care.
Neck pain or tenderness
Severe or increasing headache
Deteriorating conscious state
Double vision
Seizure or convulsion
Weakness or tingling/burning in arms or legs
Loss of consciousness
Increasingly restless, agitated or combative
If Red Flag(s) identified, complete only Step D Action to be taken.
Please complete the following steps if Red Flag(s) have not been identified.
This tool is a quick reference, to be completed to help identify a suspected concussion and to
communicate this information to parent/guardian.
Appendix C Page 2 of 4
Other Sign(s) and Symptoms(s)
If red flag(s) not identified continue and complete the following steps (as applicable) and Step D Action
to be taken.
Other Concussion Signs
Check for visual cues (what you see).
Lying motionless on the playing surface (no loss of consciousness)
Disorientation or confusion, or an inability to respond appropriately to questions
Balance, gait difficulties, motor incoordination, stumbling, slow laboured movements
Slow to get up after a direct or indirect hit to the head
Blank or vacant look
Facial injury after head trauma
Other Concussion Symptoms reported (what the student is saying)
Check for what the student feels.
Blurred vision
More emotional
Difficulty concentrating
“Pressure in head”
Sensitivity to light
More irritable
Difficulty remembering
Balance problems
Sensitivity to noise
Feeling slowed down
Fatigue or low energy
Nervous or anxious
Feeling like “in a fog"
“Don’t feel right”
Appendix C Page 3 of 4
STEP C: Perform Quick Memory Function Assessment
Ask the student the following questions and record the answers below. Failure to answer any one of these
questions correctly may indicate a concussion.
Note: It may be difficult for younger students (under the age of 10), students with special needs
or students for whom English is not their first language to communicate how they are feeling.
Select the most appropriate questions for the student based on his/her ability to respond.
What is your name? Answer: _________________________________________________
How old are you? Answer: ___________________________________________________
What grade are you in? Answer: ______________________________________________
What is your teacher’s name? Answer: _________________________________________
Other________________________? Answer: ____________________________________
What room are we in right now? Answer:____________________________________________
What activity/sport/game are we playing now? Answer:__________________________________
What field are we playing on today? Answer:__________________________________________
What part of the day is it? Answer:__________________________________________________
What is the name of your teacher/coach? Answer:______________________________________
What school do you go to? Answer:_________________________________________________
Appendix C Page 4 of 4
STEP D: Action to be taken
Red Flag(s) sign(s) observed and/or symptom(s) reported and EMS called. Parent/guardian (or
emergency contact) contacted. Follow the Risk Management Advisory-Transporting Students
to Hospital/Urgent Care.
Signs observed or Symptoms reported:
If there are any signs observed or symptoms reported, or if the student/athlete fails to answer any of the
above questions correctly:
a concussion should be suspected;
the student/athlete must be immediately removed from play and must not be allowed to return to
play that day even if the student/athlete states that he/she is feeling better; and
the student/athlete must not leave the premises without parent/guardian (or emergency contact)
In all cases of a suspected concussion, the student/athlete must be examined by a medical doctor or nurse
practitioner for diagnosis and must follow the Student Concussion and Head Injury Policy.
No signs observed or symptoms reported:
Student to be monitored for 24 hours and removed from physical activity (where teacher/coach
determines monitoring is applicable or where teacher/coach is not sure).
Monitoring of the student/athlete to take place at home by parents and at school by school staff.
To monitor for signs and symptoms parents/guardians can use the chart on the front of this
information form.
If any signs or symptoms emerge, the student/athlete needs to be examined by a medical doctor or
nurse practitioner as soon as possible that day.
School Contact/Teacher Advisor Name: ____________________ Date: _______________
Under the direction of the Ontario Ministry of Education and under the legal authority of the Education Act, Grand Erie District School Board
collects this information in order to fulfil its commitment to promote the health and safety of students by raising awareness, identification, and
prevention of concussion injuries, and managing diagnosed concussions. In accordance with the Municipal Freedom of Information and
Protection of Privacy Act this information will be used solely to assess the student’s Return to Learn and Return to Physical Activity. It will be
retained in the Ontario Student Record [OSR] for one year after the student graduates or transfers out of the school. The Ministry of Education
may also request school reports on concussion activity. If you have any questions or concerns about the collection of information on this form
please contact the school principal.
Following the completion of this form (Appendix C), an OSBIE Incident Report form must be completed, indicating that
the tool has been completed and the parent/guardian has received copies of Appendix C and Appendix D2.
*The original copy is filed with the principal *Duplicate copy provided to parent/guardian
Reproduced and adapted with permission from Ophea, [Ontario Physical Education Safety Guidelines, 2018]