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Run: Concussion Baseline and Return-to-Play Protocol Documentation

Document a concussion incident, immediate removal from play, medical clearance, and step-by-step return-to-play in one form. Use it to keep coaches, athletic...

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Incident and Athlete Identification

Athlete Name (required)

Date of Birth

Collect only if needed to distinguish the athlete from others with similar names.

Team or Program (required)

Sport (required)

Date of Incident (required)

Time of Incident

Location of Incident

Concussion Screening and Immediate Response

Was a concussion suspected? (required)

Observable Signs

Reported Symptoms

Was the athlete removed from play immediately? (required)

Reason for Removal

Explain why the athlete was not removed, if applicable.

Immediate Actions Taken (required)

Medical Evaluation and Clearance

Has a medical evaluation been completed? (required)

Evaluating Provider Type

Provider Clearance Date

Clearance Status

Restrictions or Recommendations

Document any activity limits, academic accommodations, or monitoring instructions.

Graduated Return-to-Play Progression

Has graduated return-to-play started? (required)

Step 1: Symptom-limited activity completed?

Step 2: Light aerobic exercise completed?

Step 3: Sport-specific exercise completed?

Step 4: Non-contact training drills completed?

Step 5: Full-contact practice completed?

Step 6: Returned to full play?

Progress Notes

Acknowledgment and Submission

Submitter Name (required)

Submitter Role (required)

Acknowledgment (required)

Yes No N/A

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Email (required)

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