Concussion Report - King Edward's School

Report of new suspected concussion

Use this form to report any accident, sports or otherwise, where concussion is suspected. To report an accident where concussion is not suspected, go to kes.org.uk/accident
Surname of casualty*
Forename of casualty*
mkw e-mail
example@example.com
Name of the person completing this form*
Date of accident*

DayMonthYear
Is the injured person a pupil, a visitor, or a member of Staff?*

KES pupilVisiting pupil
Where from?*
If they are a visitor, which school or organisation did they come from?
What type of activity were they doing when they were injured?*

Normal lessonGames or PE lessonSports practice at lunch or after schoolSports match/fixtureClubFree time - eg break, lunch, before/after schoolSchool tripOther
Name of teacher supervising activity*
If this was free time with no supervising teacher, state NONE
Site*

At King Edward's SchoolOther
Location*
State where they were (which playing field etc) when the accident happened
Activity*

RugbyHockeyOther
What happened?*
Describe exactly how they were injured
If possible please provide an e-mail address for one or both parents. We'll then automatically e-mail parents with the school's concussion protocol.
1st parent's e-mail address
example@example.com
2nd parent's e-mail address
example@example.com
Visible clues at time of injury*

No visible cluesLoss of consciousness or responsivenessLying motionless on the playing surfaceFalling unprotected to the playing surfaceDisorientation or confusion, staring or limited responsiveness, or an inability to respond appropriately to questionsDazed, blank, or vacant lookSeizure, fits, or convulsionsSlow to get up after a direct or indirect hit to the headUnsteady on feet / balance problems or falling over / poor coordination / wobblyFacial injuryOther
Physical symptoms*

No physical symptomsHeadache"Pressure in head"Balance problemsNausea or vomitingDrowsinessDizzinessBlurred visionMore sensitive to lightMore sensitive to noiseFatigue or Iow energy"Don't feel right"Neck PainOther
Changes in emotions

More emotionalMore IrritableSadnessNervous or anxiousOther
Changes in thinking

Difficulty concentratingDifficulty rememberingFeeling slowed downFeeling like "in a fog"Other
Symptoms

HeadacheDizzinessNausea or vomitingConfusionDifficulty rememberingDrowsinessLoss of consciousnessBalance problemsBlurred visionSeizure or convulsionNeck PainOther
Late-onset symptoms

HeadacheDizzinessNausea or vomitingConfusionDifficulty rememberingDrowsinessLoss of consciousnessBalance problemsBlurred visionSeizure or convulsionNeck PainOther
Injuries
Concussion protocol handed or e-mailed to parents?*

YesNo
Treatment*
Responder*
What happened next*

Parents took them, having been advised to contact NHS111They went to hospital in an ambulanceOther
You haven't entered any e-mail addresses for parents - it would be really useful if you could do so. If you can find an e-mail address to add, please do scroll back up this page.
Any other information
Should be Empty:

You haven't entered any e-mail addresses for parents - it would be really useful if you could do so. If you can find an e-mail address to add, please do scroll back up this page.