Brain Injury Form

Brain Injury Form

This form is to be filled out by the school nurse to help identify students who have had a mild to severe brain injury/concussion in the LRSD. If you are a parent, please contact your school nurse to notify them of this information.
Student Name (First and Last Name)*

First NameLast Name
Student ID Number*
Student Date of Birth*
Parent/Guardian Name and Number*
School Student Attends*
Name of Person Submitting Form (First, Last, title)*
Date of Injury*

MonthDayYear
Date
Mechanism of Injury (How did the student get injured?)*

Sports RelatedMotor Vehicle AccidentFallPenetrating Brain InjuryAnoxic Brain InjuryShaken Baby SyndromeInflicted Injury-impact against an object (pole, desk, etc.) or assaultOther
If involved in Athletics at school-What Sport?*
What Hospital or Physician is involved in the care of the student? Please provide contact information.
Accomodations or support equipment as advised per: Neuropsychologist, MD, DO, Advanced Practice Nurse, Certified Athletic Trainer, of Physician Assistant*

HelmetWheelchairWalkerFrequent Nurse visits for brain rest during school dayExtra Testing Time1/2 day of SchoolSpeech TherapyPhysical TherapyOccupational TherapyPrescribed MedicationLimited Amount of Screen TimeComplete Brain Rest-Time off from schoolTime off from Sports-Return to PlayN/AOther
If other please explain
Nurse Checklist. Please indicate below who you have notified/steps taken.*

Department Head (Head Counselor)Athletic Trainer (secondary schools)PrincipalDirector of Health ServicesObtain a release of information from Doctor
Should be Empty: