Head Injury/Concussion Report Form

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This form is to be complete by the DC/CA/RS, to report the particulars of a member returning to play following a head injury or the suspicion of a concussion having been sustained.

Email *

Name of Person Submitting Report *

Daytime Phone Number *

Date of Incident *

YYYY

Was an injury sustained as a Pony Club activity? *

Yes

When did a physician sign off on the Concussion Return to Play From? *

YYYY

Did the physician understand what was being asked of him/her in signing the Concussion Return to Play Form? *

Yes

When did the member/parent sign off on the Concussion Return to Play Form? *

YYYY

Did the member/parent understand what was being asked of him/her in signing the Concussion Return to Play Form?
*

Yes

How many mounted meetings/activities did the member miss? *

Did the member participate in unmounted meetings, but not mounted meetings for a period of time? *

Yes

Send me a copy of my responses.

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