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Sample Tool to Identify a Suspected Concussion

This tool was adapted from Davis GA, et al. Br J Sports Med 2017;0:1. doi:10.1136/bjsports-2017-097508CRT5

This sample tool, completed by school staff (for example, Teachers/Coaches/Intramural Supervisors), is used to identify the signs and/or symptoms of a suspected concussion, to respond appropriately and to communicate this information and follow-up requirements to parents/guardians. This tool may also be used for continued monitoring of the student. Complete the appropriate steps.

Student name:
Time of Incident:
Date:
Teacher/Coach:

Identification of Suspected Concussion: If after a jarring impact to the head, face or neck or elsewhere on the body, an impulsive force is transmitted to the head (observed or reported), and the individual (for example, Teacher/Coach) responsible for that student suspects a concussion, the Steps within this tool must be taken immediately.

Step A: Red Flags Signs and Symptoms

Check for Red Flag sign(s) and or symptom(s).

If any one or more red flag sign(s) or symptom(s) are present, call 911, followed by a call to parents/guardians/emergency contact.

Red Flag Signs and Symptoms:

Deteriorating conscious state
Double vision
Increasingly restless, agitated or combative
Loss of consciousness
Neck pain or tenderness
Seizure or convulsion
Severe or increasing headache
Vomiting
Weakness or tingling/burning in arms or legs

Step B: Other Signs and Symptoms

If Red Flag(s) are not identified continue and complete the steps (as applicable) and Step E: Communication to Parents/Guardians

Step B1: Other Concussion Signs

Check visual cues (what you see).

Balance, gait difficulties, motor incoordination, stumbling, slow laboured movements
Blank or vacant look
Disorientation or confusion, or an inability to respond appropriately to questions
Facial injury after head trauma
Lying motionless on the playing surface (no loss of consciousness)
Slow to get up after a direct or indirect hit to the head

Step B2: Other Concussion Symptoms Reported (What the Student is Saying)

Check what students report feeling.

Balance problems
Blurred vision
Difficulty concentrating
Difficulty remembering
Dizziness
“Don’t feel right”
Drowsiness
Fatigue or low energy
Feeling like “in a fog"
Feeling slowed down
Headache
More emotional
More irritable
Nausea
Nervous or anxious
“Pressure in head”
Sadness
Sensitivity to light
Sensitivity to noise

If any sign(s) or symptom(s) worsens call 911.

Step B3: Conduct Quick Memory Function Check

Questions may need to be modified for very young students, the situation/activity/sport and/or students receiving special education programs and services. Failure to answer any one of the questions correctly indicates a suspected concussion. Record student responses.

Is it before or after lunch?
What activity/sport/game are we playing now?
What field are we playing on today?
What is the name of your Teacher/Coach?
What room are we in right now?
What school do you go to?

Step C: When sign(s) are observed and/or symptom(s) are reported, and/or the student fails to answer any of the Quick Memory Function questions correctly

Actions required:

  • a concussion should be suspected;
  • the student must stop participation immediately and must not be allowed to return to play that day even if the student states that they are feeling better; and
  • the student must not:
    • leave the premises without parent/guardian (or emergency contact) supervision;
    • drive a motor vehicle until cleared to do so by a medical doctor or a nurse practitioner;
    • take medications except for life threatening medical conditions (for example, diabetes, asthma).

The Teacher/Coach informs the parent/guardian that the student needs an urgent medical assessment (as soon as possible that day) by a medical doctor or nurse practitioner. Medical doctors and nurse practitioners are the only healthcare professionals in Canada with licensed training and expertise to diagnose a concussion; therefore, all students with a suspected concussion must undergo evaluation by one of these professionals. In rural or northern regions, the medical assessment may be completed by a nurse with pre-arranged access to a medical doctor or nurse practitioner.

The parents/guardians must be provided with a completed copy of this tool and a copy of a Medical Assessment Form. The Teacher/Coach informs the principal of incident.

Step D: If there are no signs observed, no symptoms reported, and the student answers all questions in the Quick Memory Function Check correctly but a possible concussion event was recognized by teacher/coach.

Actions required:

  • The student must stop participation immediately and must not be allowed to return to play that day even if the student states that they are feeling better. Principals must be informed of the incident.
  • The Teacher/Coach informs the parent/guardian of the incident and that the student attends school and requires continued monitoring for 24 hours as signs and or symptoms can appear hours or days after the incident:
    • If any red flags emerge call 911 immediately.
    • If any other sign(s) and/or symptom(s) emerge, the student needs an urgent medical assessment (as soon as possible that day) by a medical doctor or nurse practitioner.
    • The parent/guardian communicate the results of the medical assessment to the appropriate school personnel using a Medical Assessment Form.
    • If after 24 hours of monitoring no sign(s) and or symptom(s) have emerged, the parent/guardian communicate the results to the appropriate school official using the school’s process and/or form. The student is permitted to resume physical activities. Medical clearance is not required.

Step E: Communication to Parents/Guardians

Summary of Suspected Concussion Check – Indicate appropriate results and follow-up requirements.

Your child/ward was checked for a suspected concussion (that is, Red Flags, Other Signs and Symptoms, Quick Memory Function Check) with the following results:

Red Flag sign(s) were observed and/or symptom(s) reported and emergency medical services (EMS) called.
Other concussion sign(s) were observed and/or symptom(s) reported and/or the student failed to correctly answer all the Quick Memory Function questions.
No sign(s) or symptom(s) were reported, and the student correctly answered all of the questions in the Quick Memory Function Check but a possible concussion event was recognized. Student attends school, no physical activity, with continued monitoring at school and home for 24 hours. Continued monitoring is required (consult Step D).
Teacher/Coach/Intramural Supervisor signature (optional):

Forms for parents/guardians to accompany this tool:

The Medical Assessment Form

Parent/Guardian must communicate to the Principal/Designate the results of the 24-hour monitoring (using school process/form) period:

Results of the Medical Assessment
No concussion sign(s) and/symptom(s) were observed or reported after the 24 hours monitoring period.