Concussion Notification Form

When you have submitted this form, NZR and your local Provincial Union will:

provide support related to return to play and medical appointments.
send an email to notify the player, provincial union and school/club of the suspected concussion and process for return to play.

Please note: The Community Concussion Management Pathway is being trialled in Otago, Hawkes Bay, North Harbour and Wairarapa-Bush and our aim is to scale the programme nationwide in 2025.

Were any of these Red Flags present? (Please select all that apply)*

Player's First Name

Player's Last Name

Player's Email

Player's School or Club

Your Name

Your Contact Number (No spaces)

What is your relationship to the player? (Please select all that apply)*

Coach

Manager

Parent

Physio

Team Medic

Teammate

Partner/Spouse

School/Club Representative

Other

Date of Suspected Concussion

Were any of the following signs or symptoms observed? (Please select all that apply)*

How did you find out about the suspected concussion? (Please select all that apply)

I witnessed the incident

The player reported it to me during the game or training

The player reported it to me after the game or training

The player reported delayed symptoms up to 48 hours after the event

Another player reported it to me

Team staff reported it to me

A spectator reported it to me

Other

I have read and agree to the terms of the New Zealand Rugby Concussion Management Pathway Privacy Statement

NZR Concussion Management Pathway Privacy Statement