On-Field Concussion Incident Report
Date of Incident
Time of Incident
Location
Team/Club
Athlete Name
Athlete Age
Athlete Gender
Female
Male
Other
Incident Details
Description of Incident
Witnesses
Observed Signs & Symptoms
Signs Observed
Symptoms Reported
Immediate Action Taken
First Aid / Medical Action
Did athlete return to play?
No
Yes
Additional Notes
Report Completed By
Name
Role (e.g. coach, medic, referee)
Signature
Date