Concussion Incident Report Form

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CONCUSSION INCIDENT FORM
INCIDENT REPORT FORM
Participant Information
Date:
Last Name:
First Name:
Phone:
Province:
Gender
Age:
Male
Female
Club / League:
Relevant other medical conditions
INCIDENT INFORMATION REPORT
Date of incident:
Time of first intervention:
Time of medical support:
arrival:
Describe the incident
Conditions: (describe any significant information like surface quality):
Actions Taken:
sent home
sent to hospital
back on the ice
After intervention, the individual was:
Form completed by:
Print
Date
Signature
Information provided in this form will remain private and confidential.
COMPLETED FORMS MUST BE SUBMITTED TO RINGETTE CANADA
ringette@ringette.ca
It’s better to miss one game than the whole season.”
- U.S. Department of Health and Human Services Centres for Disease Control and Prevention.
Version 1 - Fall 2016

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