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 Name
Last 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
*
-
Month
-
Day
Year
Date
Mechanism of Injury (How did the student get injured?)
*
Sports Related
Motor Vehicle Accident
Fall
Penetrating Brain Injury
Anoxic Brain Injury
Shaken Baby Syndrome
Inflicted Injury-impact against an object (pole, desk, etc.) or assault
Other
If involved in Athletics at school-What Sport?
*
Please Select
Football
Soccer
Basketball
Volleyball
Track
Cheerleading
Dance
Cross Country
Wrestling
Swimming
Baseball
Softball
Other
N/A
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
*
Helmet
Wheelchair
Walker
Frequent Nurse visits for brain rest during school day
Extra Testing Time
1/2 day of School
Speech Therapy
Physical Therapy
Occupational Therapy
Prescribed Medication
Limited Amount of Screen Time
Complete Brain Rest-Time off from school
Time off from Sports-Return to Play
N/A
Other
If other please explain
Nurse Checklist. Please indicate below who you have notified/steps taken.
*
Department Head (Head Counselor)
Athletic Trainer (secondary schools)
Principal
Director of Health Services
Obtain a release of information from Doctor
Submit
Should be Empty: