Rugby Concussion Immediate Report Form
Player Information
Name
Date of Birth
Team/Club
Player Number
Incident Details
Date
Time
Location
Opponent
Match or Training
Match
Training
Concussion Event
Describe How Injury Happened
Signs/Symptoms Observed
Loss of Consciousness
Yes
No
Unknown
Memory Loss (Amnesia)
Before Impact
After Impact
None
Unknown
Immediate Action Taken
Action Taken
Removed from Play?
Yes
No
Medical Attention Provided?
Yes
No
If yes, please specify who provided medical attention:
Reporter Details
Name
Role/Position
Report Date