1. Appendix I: Student Concussion Diagnosis       Report
      1. TO BE COMPLETED BY THE SCHOOL PRINCIPAL


     

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    Appendix I: Student Concussion Diagnosis       Report



    TO BE COMPLETED BY THE SCHOOL PRINCIPAL

    NIAGARA CATHOLIC DISTRICT SCHOOL BOARD

    Student Concussion Diagnosis Report

        
    School:
    		Principal:
    Student(s) Name(s) Date of Birth Documentation for a Diagnosed Concussion - Return to School/Return to Physical Activity Plan

    in Place     		   Status of

    Return to School/

    Return to Physical Activity Plan Completed (Y) Ongoing (N)

    YYYY/MM/DD
    Surname
    		Given Name
    1.
    YES
    NO
    YES
    NO
    Date/Location of incident:
    		Circumstances causing concussion:
    2.
    YES
    NO
    YES
    NO
    Date/Location of incident:
    		Circumstances causing concussion:
    3.
    YES
    NO
    YES
    NO
    Date/Location of incident:
    		Circumstances causing concussion:
    4.
    YES
    NO
    YES
    NO
    Date/Location of incident:
    		Circumstances causing concussion:
    5.
    YES
    NO
    YES
    NO
    Date/Location of incident:
    		Circumstances causing concussion:
    Annual Concussion Awareness Training (to be completed by the Last Wednesday in September in honour of Rowan’s Law day.
    Staff Completed on:
    		DATE      
    Comments:
     


     

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