Concussion Report What to Do When an athlete has a suspected or confirmed concussion, they are required by law to be removed from sport immediately and remain removed until cleared to return by a Doctor or Nurse Practitioner. (Rowan’s Law (Concussion Safety), 2018) Remove athletes with suspected concussions from sport: Render aid and call 911 if necessary; Remove the athlete immediately, even if they appear ok; Send the athlete to a doctor or nurse practitioner for a clearance. Report concussions to parents and TO: Report to parents if the athlete is under 18; Report suspected & confirmed concussions using this form. Abide by return-to-sport protocols: Do not allow the athlete to return without a written clearance from a doctor or nurse practitioner; Follow the return-to-sport protocol provided, if not provided use the one in the Policy. Concussion Reporting Guidelines This form is for reporting suspected concussions, concussion clearances, confirmed concussions, return-to-sport protocols, and completion of RTS protocols. Coaches and Officials of events taking place in Ontario are Designated Persons under Rowan’s Law (Concussion Safety), 2018 and are required to report concussions and suspected concussions. Any Coach, Official, parent, or athlete can use this form to report a suspected or confirmed concussion, concussion clearance, return-to-sport protocol, or completion of a return-to-sport protocol. Once a suspected concussion has been reported, use this form to report subsequent events: confirmation, clearance, return-to-sport protocol, and/or completion of return-to-sport protocol. For more information about the concussion reporting and return-to-sport process, you can review the Concussion Resources and Triathlon Ontario Concussion Policy. Contact informationYour contact information as the person submitting this report. Contact Name*Your name as the person submitting this report. First Last Contact Email Address*Your current email address as the person submitting this report. Enter Email Confirm Email Contact Phone*Your current phone number as the person submitting this report. Injured Athlete Contact Information Athlete Name*Name of the injured athlete. First Last Athlete Email Address*Email address of the injured athlete, or a parent/guardian if the athlete is under 18. Enter Email Confirm Email Athlete Phone*Current phone number of the injured athlete, or a parent/guardian if the athlete is under 18.Parent or Alternate Contact Email AddressEmail address of a parent/guardian or alternate contact, if required. Note that concussions often result in the injured athlete being unable to use screens and devices to communicate by email, so we strongly recommend including an alternate contact. Enter Email Confirm Email Alternate Contact PhoneCurrent phone number of a parent/guardian or alternate contact, if required. Type of Report What to Report You may find out about a suspected or confirmed concussion in several ways. You may be present at or called to the scene of an injury and suspect a concussion; You might receive a concussion protocol from an athlete who has a concussion from outside of triathlon; You might receive a concussion report directly from a another coach, governing body, club, or school; or, You might receive a concussion report from Triathlon Ontario. In all cases coaches and officials are required to fill out this report. This form confirms that you are aware of the concussion and informs Triathlon Ontario of each step in the process. It also allows us to fulfill the statutory requirement to inform other sports and schools. Fill out this report again each time the athlete receives a clearance, a confirmation, a return-to-sport protocol, or completes their return-to-sport-protocol. Type of Report*Please enter the type of report. You can select all that apply. Suspected Concussion (Injury) Confirmed Concussion (Doctor or Nurse Practitioner's report) Return to Sport Protocol (If provided by MD or NP) Completion of Return to Sport Protocol Clearance (Written clearance from MD or NP) Suspected Concussion (Injury) Circumstances of Injury*Describe the circumstances of the injury and the actions taken. Confirmation or Return-to-Sport Protocol Document Upload*Please upload a .pdf of the Doctor or Nurse Practitioner's concussion confirmation or RTS protocol. (Typically these will be supplied at the same time. Any RTS protocol issued by an MD or NP will be considered a confirmation.) Drop files here or Accepted file types: pdf. Completion of Return-to-Sport Protocol Date of Completeion of Return-to-Sport Protocol*Please enter the date that the athlete completed their RTS protocol. If required by a Doctor or Nurse Practitioner in the RTS protocol, the athlete will need to be cleared before returning to sport. If using the Triathlon Ontario RTS protocol, the athlete may return to sport on successful completion. Date Format: YYYY dash MM dash DD Clearance Document Upload*Please upload a .pdf of the Doctor or Nurse Practitioner's concussion clearance. Drop files here or Accepted file types: pdf. Notes NotesPlease enter any additional information relevant to this report.Document UploadPlease upload any additional files relevant to this report. (Accepts all file types.). Drop files here or NameThis field is for validation purposes and should be left unchanged.