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Baseline Testing Demographic Forms
Fill out the following form before completing the impact test:
www.impacttestonline.com/testing
Code: 5EQM7YECIY
Your School?
Choose
Midway
Union
Harrells
Hobbton
Lakewood
Clinton
First Name:
Your answer
Last Name
Your answer
Date of Birth (Month/Day/Year)
MM
/
DD
/
YYYY
Current Grade in School
Choose
9th
10th
11th
12th
Gender
Male
Female
Clear selection
Race
Asain
Hispanic or Latino
White
Black or African American
Native American or American Indian
Other:
Sports you play (or will play)
Cross Country
Football
Soccer
Volleyball
Golf
Tennis
Cheerleading
Basketball
Track and Field
Baseball
Softball
Wrestling
Other:
Have you ever had a concussion baseline test on the computer?
Yes
No
Clear selection
Have you ever been diagnosed with a concussion
Yes
No
Clear selection
Submit
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