High School Football Concussion Report Form
Player Information
Player Name
Jersey Number
Grade
School Name
Coach Name
Incident Details
Date of Incident
Time of Incident
Location
Opponent Team
Description of Incident
Symptoms Observed
Headache
Dizziness
Confusion
Memory Loss
Nausea
Loss of Consciousness
Other
If Other, specify
Post-Incident Actions
Was the player removed from play?
Yes
No
Was a medical evaluation conducted?
Yes
No
Describe actions taken
Report Filed By
Name
Role/Title
Date