Attachment G
Parent Weekly Surveillance Report
Form
Approved
OMB No: 0920-XXXX
Exp. Date:
Public
Reporting burden of this collection
of information is estimated at 3 minutes per response, including the
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct
or sponsor, and a person is not required to respond to a collection
of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA
(0920-XXXX).
Date __ __ / __ __ / __ __
Weekly survey: Parent
In the past week, has your child had any hits to his/her head or body that occurred during a soccer practice or game AND then developed any of the following symptoms?
YES NO
Headache
“Pressure in head”
Nausea or vomiting
Dizziness
Blurred vision
Balance problems
Sensitivity to light
Sensitivity to noise
Feeling slowed down
Feeling like “in a fog”
“Don’t feel right”
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Drowsiness
Trouble falling asleep
More emotional
Irritability
Sadness
Nervous or anxious
Loss of consciousness (passed out)
How many minutes were you unconscious (passed out)? ______minutes
In how many games did your child see playing time this week?___________
How many soccer practices did your child participate in this week? ________
| File Type | application/msword |
| File Title | Girls Soccer Survey |
| Author | Melissa Schiff |
| Last Modified By | CDC User |
| File Modified | 2015-03-23 |
| File Created | 2015-03-23 |