BROWNSVILLE INDEPENDENT SCHOOL DISTRICT
RETURN TO LEARN PROTOCOL
CLASSROOM POST-CONCUSSION OBSERVATION FORM
RTL-1
Student:
ID #:
DOB:
Gr.:
INSTRUCTOR:
SUBJECT:
TIME OF OBSERVATION:
DATE:
Campus:
Concussions are serious brain injuries that have a significant influence on the brain’s ability to
function at its normal capacity. The purpose of this observation is to record the student’s symptoms and
behaviors following a Head Injury/Concussion. Complete this form and return it immediately to the campus
“Return to Learn” team.
DIRECTIONS:
SYMPTOMS/BEHAVIORS OBSERVED (CHECK ALL APPLICABLE AREAS OBSERVED):
Increased problems paying attention or concentrating
Increased problems remembering or learning new information
Longer time needed to complete tasks or assignments
Difficulty organizing tasks, or shifting between tasks
Inappropriate or impulsive behavior during class
Greater irritability
Less ability to cope with stress
More emotional than usual
Difficulty handling a stimulating school environment (lights, noise, etc.)
Physical symptoms (headaches, dizziness, nausea, visual problems)
SYMPTOMS OF A CONCUSSION INDICATED BY THE STUDENT (CHECK ALL APPLICABLE AREAS):
Headache
Nausea
Vomiting
Balance problems
Dizziness
Greater irritability
Visual Problems
Fatigue
Sensitivity to light
Sensitivity to noise
Dazed or stunned
Irritability
Sadness
More emotional
Nervousness
Feeling mentally “foggy”
Difficulty concentrating
Difficulty remembering
Confused about recent events
Answers questions slowly
Repeats questions
Drowsiness
Sleeping less than usual
Sleeping more than usual
Trouble falling asleep
Forgetful of recent information/conversations
Additional Observation Information:
_________________________________________________
Observer’s Signature
BISD does not discriminate on the basis of race, color, national origin, sex, religion, age, disability or
genetic information in employment or provision of services, programs or activities.
Date
10-2014
RTL-1