Concussion Injury Reporting Form (to be completed upon student's return to school)

The New York State Concussion Management and Awareness Act became effective on July 1, 2012. While not mandatory, completion of this form will allow the Center to monitor the incidence, characteristics, and follow-up assessments of concussion injuries sustained by New York State students. This information will be used to plan programs and training, create educational resources, and provide support to school health professionals in the care of students affected by head injury.

Question Title

* 1. School District Name

Question Title

* 3. Type of School

Question Title

* 4. Level

Question Title

* 5. Date / Time

Date
Time

Question Title

* 6. Injury occurred

Page1 / 4
 
25% of survey complete.

T