Concussion Registration

Concussion registration and follow-up consent

Please read this information carefully before submitting the form.

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By completing and submitting this form, you confirm that you understand and agree that:

1. Voluntary participation

Completing the injury registration form and any follow-up surveys is voluntary. You do not have to complete the form or any follow-up survey. If you choose not to participate, this will not affect your access to the HIT Kit, clinical care, support, or any services available to you.

2. What information we collect

We may collect personal and health information that you choose to provide, including:

your name and contact details
date of birth
date and details of your injury
where and how the injury occurred
symptoms and recovery information
details about your use of the HIT Kit or related services
responses to follow-up surveys sent after your injury.

3. Why we collect it

We collect this information to:

register your injury and support your care and recovery
send follow-up emails and surveys at set times after your injury
better understand concussion symptoms and recovery patterns
improve our services, patient education, and concussion management
support future research into concussion injury and recovery.

4. Follow-up contact

If you provide your contact details, we may email you at set times after your injury to invite you to complete follow-up surveys about your symptoms and recovery. Completing these surveys is optional.

5. Research use

With your optional consent, the information you provide through the registration form and any follow-up surveys may be used in future research related to concussion injury and recovery. This may include research approved after your information is collected.

6. De-identification for research

If your information is used for research, we will take reasonable steps to remove direct identifiers before analysis, reporting, publication, or presentation, so that you are not identified personally. In some cases, authorised members of the research team or ethics reviewers may need to access identifiable information for data management, linkage, audit, or verification before de-identification occurs.

7. Storage and security

Your personal and health information will be stored securely and protected against loss, misuse, unauthorised access, modification, or disclosure. Access will be limited to authorised staff, contractors, and service providers who need the information for the purposes described in this consent and our privacy policy.

8. Who we may share it with

We may share your information:

with clinicians or others directly involved in your care, where appropriate
with service providers who help us operate our website, email systems, data storage, survey tools, or analytics systems
where required or authorised by law
with approved researchers, in de-identified form where practicable and appropriate.

9. Overseas storage or processing

Some of our technology providers or data hosting services may store or process information outside New Zealand or Australia. Where this occurs, we will take reasonable steps to ensure your information is protected in a way that is comparable to applicable privacy law requirements.

10. Access and correction

You have the right to request access to the personal and health information we hold about you, and to request correction if you believe it is incorrect.

11. Withdrawal of consent

You may withdraw your consent to future follow-up contact, and you may withdraw your consent to future research use of your identifiable information, by contacting us using the details in our privacy policy. Withdrawal will not affect any use, disclosure, or research activities already undertaken before your request is received, and it may not be possible to remove information that has already been de-identified or included in analyses or publications.

12. Complaints

If you have concerns about how your information has been handled, you may contact us first. You also have the right to complain to the New Zealand Privacy Commissioner, and if Australian privacy law applies to your information, to the Office of the Australian Information Commissioner.

Consent

By ticking the boxes below and submitting the form, you consent to the collection, use, storage, and disclosure of your information as described above and in our privacy policy.

Consent(Required)

I confirm that I have read and understood the privacy information and consent to the collection, use, storage, and disclosure of my personal and health information for injury registration, follow-up contact, care, service improvement, and related administrative purposes.(Required)

Optional research consent

I consent to the information I provide through the injury registration form and any follow-up surveys being used in future research about concussion injury and recovery. I understand that, where my information is used for research, it will be de-identified before analysis, reporting, publication, or presentation, unless identifiable information is temporarily required for approved data management, linkage, audit, or ethics processes.

Privacy law acknowledgement

I understand that the collection, use, storage, disclosure, access, and correction of my information will be managed in accordance with applicable privacy laws, including the Privacy Act 2020 and Health Information Privacy Code 2020 in New Zealand, and where applicable the Privacy Act 1988 (Cth) and Australian Privacy Principles.

Name(Required)

First Last

Date of birth:

DD slash MM slash YYYY

Email(Required)

Phone(Required)

Where did this injury occur? (Region/Event/Organisation):

How long ago did the injury occur: (for example number of hours or days since injury)

How did the injury occur?

Time from injury to use of kit

HIT Kit not used

Time of injury - 2 hours

2 - 6 hours

6 - 12 hours

12 - 24 hours

24 - 48 hours

>48 hours

Immediate symptoms (tick all that apply):

None

Headache

Dizziness

Loss of balance/stumbling

Confusion

Loss of memory

Vacant/blank look

Facial injury

Incoordination

Nausea/vomiting

Very drowsy or hard to wake

Seizure or convulsion

Unusual behaviour, very confused or very irritable

Weakness in arms or legs

Unsteady on feet or slurring of speech

Loss of consciousness

Fluid leaking from ears, bruising around eyes or behind ears

Unable to remember more than 30 minutes before the injury

Neck pain

Is your headache severe or worsening? If yes, you should go immediately to the emergency department

If this is bad nausea or vomiting you should go immediately to the emergency department

This is a red flag. You should go immediately to the emergency department

Current symptoms (tick all that apply):

Headache

Dizziness

Neck pain

Sensitivity to light/noise

Balance issues

Difficulty remembering

Confusion

Brain fog

Trouble thinking clearly

Anxiety/depression

Irritability

Fatigue

Difficulty concentrating

Visual problems

Nausea/vomiting

Change to emotions

Difficulty falling asleep

Changes to sleeping

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