DOS Concussion Notification

This form is intended for use by Campus Health Services providers ONLY to convey information to the Dean of Students office regarding students needing support for concussions.

Provider Name

Provider Email

Student Name (first and last)

PID

Appointment Type

Initial appointment

Follow-up appointment

Appointment Date

UAA Start Date (only to be used for follow-up appts)

Date of Onset

Duration of Absences

First concussion report - 7 days

Second concussion report - 7 days

Provider Recommendation (for University Approved Absences)

Complete Cognitive Rest

Limited Participation in course work

Due to the severity and estimated duration of concussion symptoms, student was advised to apply for academic accommodations through the UCO Accommodations team

Yes (form will be sent to both DOS and UCO)

No (form will be sent to DOS only)

Next Appointment Scheduled

Other

DOS Concussion Notification

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