Adult Concussion Protocol Form

"*" indicates required fields

Please complete the form below and return asap to concussions@northumberlandrfu.co.uk titled Concussion Confidential. The County Office will then contact the club and other relevent groups eg, University or H.E. Coach, relevant County Representative Rugby Team Manager and Coach, within 48 hours. Please ensure you have informed the appropriate people within your club.

Name of person completing the form*

Email Address*

Position at Club/University/County*

Player's Full Name*

Player's Email Address*

Player's Date of Birth*

Date of Incident*

Does the player give permission for information to be circulated*

Yes

Player has been notified that information will be kept on file and is happy that paperwork will be kept for reference.*

Yes

Please give a detailed overview of the incident*

Player's Age Group*

Player's Club*

Lead Coach*

Player's University or College

Lead Coach

Is the player in a County, Falcons Academy, University or Rugby League squad?*

Yes

If the player is playing both University and Club Rugby, please make sure you provide contact information for both lead coaches.

If 'yes' please give contact details for coaches.

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