Workplace Concussion Screening Form
Report a recent head impact at work and help determine if medical evaluation is needed.
Employee Full Name
*
First Name
Last Name
Contact Information (Phone or Email)
*
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
Where did the head injury occur?
*
Briefly describe how the head injury happened.
*
Did you lose consciousness at any point?
*
Yes
No
Not sure
What symptoms do you have now? (Select all that apply)
*
Headache
Nausea or vomiting
Dizziness or balance problems
Confusion or memory loss
Blurred or double vision
Sensitivity to light or noise
None of the above
Other
What symptoms did you have immediately after the incident? (Select all that apply)
*
Brief loss of consciousness
Seizure or convulsions
Vomiting
Confusion or disorientation
Drowsiness or trouble staying awake
None of the above
Other
Can you safely continue working right now?
*
Yes, I feel able to continue working
No, I need to stop working
Not sure
If you have severe symptoms (e.g., repeated vomiting, seizure, trouble waking, severe confusion), acknowledge that you will seek immediate medical attention as advised.
*
I understand and will seek urgent medical care if needed
Submit Screening
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