CONCUSSION NOTIFICATION FORM

CONCUSSION NOTIFICATION FORM

Please note: this form is being trialled with select PUs. If you are outside these regions, please select "OTHER" in the PU dropdown.

Were any of these Red Flags present?

Please select all that apply

Select

Warning:

If the player reports any of these Red Flags, please get the player to A&E or urgent care immediately.

Player Information

Player's First Name*

Player's Last Name*

Player's Email*

Please ensure an accurate email as the player will receive concussion guidance information

Player's Phone Number

Provincial Union*

Select

Which competition?

Select

Player's School or Club*

eg. Napier Boys

Player's Team*

eg. NBHS U15 Blue

If known, please enter a School/Club Contact Email

They will also receive concussion notification and guidance

If known, please enter Parent/Guardian Contact Email

They will also receive concussion notification and guidance

If known, please enter their NZR PlayerID

NZR Concussion Management Pathway Privacy Statement

I have read and agree to the terms of the New Zealand Rugby Concussion Management Pathway Privacy Statement*

Your Details

Name*

Your Contact Number*

Was a Blue Card given?*

Select

What Physiotherapy Clinic are you associated with?

Details of Suspected Concussion

Date of Suspected Concussion*

Did the concussion occur at a game or training?*

Select or enter value

Was foul play involved in the incident?*

Select

If known, what position was the player on date of suspected concussion?

Select

Was the player removed from play during the game or training?*

Select

How did you find out about the suspected concussion? (Please select all that apply)*

I witnessed the incident

The player reported it to me DURING the game or training

The player reported it to me AFTER the game or training (<2hrs after)

The player reported delayed symptoms to me up to 48 hours after the event

Another player reported it to me

Team staff reported it to me

A spectator reported it to me

Other

What was the player doing when the suspected concussion occured?*

Select

How did it happen?*

Select

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