Sandwich School District

Please fill out the following form:

If you suspect a student has suffered a concussion, please complete the form below to notify the student’s School Nurse. Click here for additional contact information.

Please choose the student's school from the list below:

Your Name (required)

Your Department or Organization

Your Phone Number

Your Email Address

Students Full Name (required)

Concussion Notification:
Please provide a detailed description of injury, along with symptoms, times and dates.

As a Healthcare Provider, by checking this box, I certify that I have permission from parent or guardian to notify the School RN of a suspected concussion or MTBI.

By checking this box, I certify that I am parent, coach, teacher or other reporter not held to HIPAA regulations