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. Please use this data collection tool to complete the on-line Emergency Data Reporting Form at While not mandatory, submitting this information 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. Upon completion and submission of this form, you will have the opportunity to print a copy for your own records.

1.SchoolDistrictName: ______

2.Region/County:

Capital (Albany, Columbia, Greene, Saratoga, Schenectady, Rensselaer, Warren, Washington)

Central (Cayuga, Cortland, Madison, Onondaga, Oswego, Tompkins)

Finger Lakes (Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Wayne, Wyoming, Yates)

Long Island (Nassau, Suffolk)

Mid-Hudson (Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester)

Mohawk Valley (Fulton, Hamilton, Herkimer, Montgomery, Oneida, Schoharie)

New York (Bronx, Kings, Queens, New York, Richmond)

North Country (Clinton, Essex, Franklin, Jefferson, Lewis, St. Lawrence)

Southern Tier (Broome, Chemung, Chenango, Delaware, Otsego, Schuyler, Steuben, Tioga)

Western (Allegany, Cattaraugus, Chautauqua, Erie, Niagara)

3.TypeofSchool:  Public BOCES Nonpublic/Private

 Charter 4201 (NYS Operated Schools) Other

4.Level: PreK/KMiddle School PreK – 12

 ElementaryHigh School Other

5.DateofInjury:_____/_____/_____TimeofInjury:_____/_____/_____

6.Injury occurred:

BeforeschoolDuringschoolAfterschoolActivitynotrelatedtoschool

If before or after school, incident occurred during: ______

7. Individual injured was a: Student Staff member

8. Doesthisindividualhaveapreviousdiagnosisoftraumaticbraininjuryorconcussion?

Yes NoUnknown

9.Locationofindividualwheninjuryoccurred:

 Bus Cafeteria Classroom/Hallway Gym Outdoors SchoolOffice Other

10. Injurywascausedfromcontactwith:

Anotherperson Equipment Floor/ground Wall/post Other

11. Ifinjuryoccurredduringasportingevent,pleaseindicatesport:

 Baseball/softball Football Skiing Track

 Basketball Golf Soccer Volleyball

 CheerleadingGymnastics Swimming/diving Wrestling

 Fieldhockey Lacrosse Tennis Other

12. WasaConcussionSidelineAssessmentperformed?

Yes NoUnknown

13. If a Concussion Sideline Assessment was performed, who did the assessment?

 Coach School Medical Director Certified Athletic Trainer

 School Nurse Other: ______ Sideline Assessment not performed

14. IfaConcussionSidelineAssessmentwasperformed,whichtoolwasused?

 Standardized Assessment of Concussion (SAC) Other: ______

 Sport Concussion Assessment Tool 2 (SCAT2) Sideline assessment not performed

15. Wasthepersonseenbyamedicalprovider(privateprovider/ER/UrgentCare)?

Yes NoUnknown

16. ThemedicalproviderisaNewYorkStatelicensed:

 MD/DO  NP  PA

17. Was the diagnosis of concussion confirmed by the medical provider?

Yes NoUnknown

18. Was the Initial Concussion Sideline Assessment shared with the School Nurse?

Yes No

19. Did this student have a baseline neurocognitive assessment?

Yes NoUnknown

20. What neurocognitive assessment tool was utilized for the baseline assessment?

 Acute Concussion Evaluation (ACE)

 Immediate Post-Concussion Assessment & Cognitive Testing (ImPACT)

 N/A

 Other:______

21. Who performed the neurocognitive assessment?

 School Nurse School Medical Director Neuropsychologist  N/A

 Other:______

22. Does your school have a Concussion Management Plan?

Yes No

23. Does your school have a Concussion Management Policy?

Yes No

24. Was the School Medical Director notified of the incident?

Yes No

25. Was a debriefing (follow-up) meeting held concerning this incident?

Yes No

26. We value your feedback and suggestions for collecting data on concussions in the school setting.

Your comments are appreciated.