Gymnastics BC - GymBC Suspected Concussion Report Form Updated Nov 7, 2021

Gymnastics BC Suspected Concussion Report Form

Please complete this form in full (one per suspected concussion) and submit to Gymnastics BC within 48 hours of the incident. Only currently registered Gymnastics BC members are covered by the Sport Accident Insurance Policy (birthday party, field trip, and other one-time participants are NOT covered).

*To access the Concussion Recognition Tool 5 Click Here

Individual Experiencing Injury

Date of Incident *

Individual Experiencing Injury Information

You will receive your receipt by email.

First name *

Last name *

Email *

Mobile *

Gender

Date of birth *

Address

City

State/Province

Zip/Postal code

Other phone (home or work)

Please Select Their GymBC Member Club: *

Role *

Gymnast Level *

Rec/Active Start Parent and Tot Rec/Active Start Preschool Age Rec (School Age) Rec (Adult) Interclub (school age) Comp (including Xcel)

Other:

Years of Experience *

First time 0-1 2-3 4-9 10+

Supervising Coach *

Please include the first and last name of the supervising coach.

Injury details

Time of injury *

How many minutes into training did the injury occur?

Occasion: *

Symptoms *

If there is concern after an injury including if ANY of the following signs are observed or complaints are reported, then the participant should be safely and immediately removed from activity. If no licensed healthcare professional is available, call an ambulance for urgent medical assessment.

Red Flag Symptoms require you to call an ambulance:

-Neck pain or tenderness

-Severe or increasing headache

-Deteriorating Conscious state

-Double Vision

-Seizure or Convulsion

-Vomiting

-Weakness or tingling/burning in arms or legs

-Loss of Consciousness

-Increasingly restless, agitated, or combative

How did the incident occur? *

Approach Element Practice Mid-routine Mount Spotting Dismount/Landing/Takeoff Stretching/Conditioning/Warm-up

Other

Apparatus/Area *

Select all that apply

Situation *

Fall (slip, trip, pushed, lost balance) Over-rotated Under-rotated Missed Collison with Person Collison with Object Other

What skill was being attempted at the time of the incident? *

What progressions were taught before the gymnast attempted the skill? *

Was spotting (or other aids) used? *

What precautions were taken to prevent the incident? *

Please provide details on how the incident happened (include any special or unusual circumstances related to the incident): *

Action Taken

What action did you take? *

By whom (First and Last Name) *

Phone *

Describe:

Name of hospital / clinic (if applicable)

Transported by:

When was parent informed:

Informed by:

Coach Staff Other

First and Last Name

Witness

Witness #1

First name *

Last name *

Mobile

What is their role?

Witness #2

First name *

Last name *

Mobile

What is their role?

If it is likely that the injured party will make an insurance claim, please ensure that they receive a copy of the GameDay Sport Accident Claim Form and instructions on making claims. These are available on the GBC website. The claim form must be submitted to Gymnastics BC within 30 days of the incident. Gymnastics BC will forward the form to GameDay Insurance. Please keep all documentation and receipts related to medical care from the incident to facilitate the claims process.

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Submitted by:

First name *

Last name *

Email *

Mobile

Other phone

Role

Electronic signature *

Please sign your name inside the box

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