Pediatric Brain Injury Report Form
Please provide details about the child’s brain injury incident to support appropriate follow-up. All information will be handled with confidentiality.
Child’s Full Name
*
First Name
Last Name
Child’s Age
*
Child’s Gender
*
Male
Female
Non-binary
Prefer not to say
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Brief Description of the Incident
*
Immediate Symptoms Observed
*
Loss of consciousness
Vomiting
Headache
Confusion
Drowsiness
Seizures
Other
Actions Taken Immediately After Injury
*
Reporter’s Name and Relationship to Child
*
Reporter’s Contact Information (phone or email)
*
I confirm that the information provided is accurate and I consent to its use for follow-up regarding this incident.
*
I agree
Submit Report
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