OFF-CAPE School or Pre-Schools

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. Please enter as much information as possible about the student’s school: Provide the school’s name, town/city and state. Every effort will be made to contact the school. Please advise parent/guardian to contact school also.

Please enter the School Name, Town and State

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