Teacher Feedback Form
Student's Name ___________________________
Date ___________________________
Date of Concussion___________________________
Student: you have been diagnosed with a concussion. It is your responsibility to gather data from your teachers. A day or two before your next doctor's appointment or at the request of your school nurse/health tech, go around to all of your teachers (especially the CORE classes) and ask them to fill in the boxes below based upon how you are currently functioning in their class(es).
Teachers: Thank you for your help with this student. Your feedback is very valuable. We do not want to release this student back to physical activity if you are still seeing physical, cognitive, and emotional or sleep/energy symptoms in your classroom(s). If you have any concerns, please state them below.
2. Class taught
2. Class taught
2. Class taught
Teacher name and class information goes here
Academic adjustments information goes here
Concussion symptoms information goes here
☐ Yes ☐ No
Date: __________
Signature: __________
2. Class taught
2. Class taught
Teacher name and class information goes here
Academic adjustments information goes here
Concussion symptoms information goes here
☐ Yes ☐ No
Date: __________
Signature: __________
2. Class taught
2. Class taught
Teacher name and class information goes here
Academic adjustments information goes here
Concussion symptoms information goes here
☐ Yes ☐ No
Date: __________
Signature: __________
2. Class taught
2. Class taught
Teacher name and class information goes here
Academic adjustments information goes here
Concussion symptoms information goes here
☐ Yes ☐ No
Date: __________
Signature: __________