Report Of Head Injury During Sports Season Form

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The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
250 Washington Street, Boston, MA 02108-4619
CHARLES D. BAKER
Governor
KARYN E. POLITO
R
H
I
D
EPORT OF
EAD
NJURY
URING
Lieutenant Governor
S
S
PORTS
EASON
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH
Commissioner
This form is to report head injuries (other than minor cuts or bruises) that occur during a sports season. It should be
returned to the athletic director or staff member designated by the school and reviewed by the school nurse.
For Coaches: Please complete this form immediately after the game or practice for head injuries that result in the
student being removed from play due to a possible concussion.
For Parents/Guardians: Please complete this form if your child has a head injury outside of school related
extracurricular athletic activities.
Student’s Name
Sex
Date of Birth
Grade
School
Sport(s)
Home Address
Telephone
Date of injury: _________________
Did the incident take place during an extracurricular activity? _____ Yes ____ No
If so, where did the incident take place? ____________________________________________________
Please describe nature and extent of injuries to student:
For Parents/Guardians:
Did the student receive medical attention? yes_____ no_____
If yes, was a concussion diagnosed? yes____ no ______
I HEREBY STATE THAT TO THE BEST OF MY KNOWLEDGE, MY ANSWERS TO THE ABOVE QUESTIONS
ARE COMPLETE AND CORRECT.
Please circle one: Coach or Marching Band Director
Parent/Guardian
Name of Person Completing Form (please print): _____________________________________________
Signature _______________________________________
Date _______________

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