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
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.