The NFHS (National Federation of State High School Associations) identifies concussions through a combination of observable signs spotted by coaches, officials, and parents, along with symptoms reported by the athlete. No single test confirms a concussion on the sideline. Instead, the NFHS framework relies on recognizing a pattern of physical, cognitive, and behavioral changes after an impact, then removing the athlete from play immediately for further evaluation.
Signs That Others Can Observe
The NFHS distinguishes between signs (what you can see from the outside) and symptoms (what the athlete feels). Coaches, parents, officials, and teammates are all considered part of the identification chain. The official NFHS list of observable signs includes:
- A dazed, vacant, or stunned appearance
- Confusion about assignment or position
- Forgetfulness
- Uncertainty about the game, score, or opponent
- Clumsy movements
- Slow responses to questions
- Mood, behavior, or personality changes
- Inability to recall events before or after the hit or fall
These signs can appear immediately or develop over minutes to hours. A player who seems fine right after a collision may start showing confusion or clumsiness a quarter later. That delayed onset is one reason the NFHS emphasizes continued monitoring, not just a quick check right after impact.
Symptoms the Athlete Reports
Athletes don’t always look injured from the outside. Many concussion indicators are internal, which is why the NFHS stresses asking the player directly how they feel. The official symptom list includes:
- Headache or “pressure” in the head
- Neck pain
- Balance problems or dizziness
- Nausea
- Double or blurry vision
- Sensitivity to light or noise
- Feeling sluggish, hazy, or mentally foggy
- Concentration or memory problems
- Confusion
- “Not feeling right” or “feeling down”
That last item matters more than it might seem. Many athletes can’t articulate what’s wrong but know something is off. The NFHS treats a vague “I don’t feel right” as a legitimate warning sign that warrants removal from play, even if the athlete can’t point to a specific symptom like headache or dizziness.
A key challenge is that some athletes will downplay or hide symptoms to stay in the game. This is why the NFHS places identification responsibility on everyone around the athlete, not just the athlete themselves.
Sideline Assessment Tools
When a possible concussion is suspected, more structured evaluation tools can help confirm the concern. The most comprehensive instrument for immediate sideline assessment is the Sport Concussion Assessment Tool, currently in its sixth version (SCAT6). It tests multiple domains in one sitting and is designed for use within the first 72 hours after injury.
The SCAT6 incorporates several individual tests that can also be used on their own:
- Balance Error Scoring System (BESS): The athlete stands in specific positions while evaluators count balance errors. More than 17 errors across trials suggests a concussion.
- Standardized Assessment of Cognition (SAC): A quick test of orientation, memory, and concentration. A total score below 26, or any sub-score below the athlete’s baseline, raises concern.
- King-Devick Test: A rapid number-reading test that measures eye movement and attention. Taking more than 4 seconds longer than the athlete’s baseline time suggests impairment.
- Vestibular Ocular Motor Screening (VOMS): Tests eye tracking and head movement. If the athlete reports more than two symptoms (dizziness, headache, nausea, or fogginess) during the screening, concussion is suspected.
These tools work best when the athlete has a baseline score from preseason testing to compare against. Without a baseline, evaluators rely on established cutoff values and clinical judgment. No single sideline tool is perfect on its own, which is why the NFHS approach layers observation, athlete self-reporting, and structured testing together.
The “When in Doubt, Sit Them Out” Rule
The core NFHS policy is straightforward: any athlete suspected of having a concussion must be removed from play immediately. They cannot return to practice or competition that same day, regardless of how quickly symptoms seem to resolve. This applies across all NFHS-governed sports.
Returning to play requires written clearance from a licensed healthcare provider. The NFHS does not allow coaches, parents, or the athletes themselves to make the return decision. Each state has its own specific concussion management laws that build on the NFHS framework, and those state requirements are covered in the NFHS concussion training course.
Required Training for Coaches and Officials
The NFHS partnered with the CDC to create a free online course called “Concussion in Sports,” available through the NFHS Learning Center. The course takes about one hour and covers how to recognize a suspected concussion, what to do when one is identified, and the protocols for safely returning athletes to play. Many states require coaches and officials to complete this course before the season begins.
The course is built around a practical principle: you don’t need medical training to spot the warning signs. A coach who notices a player looking dazed after a hit, or a parent who hears their child complain of a headache after a game, has enough information to start the process. Identification is the first step. Diagnosis comes from a healthcare provider.
The 6-Step Return to Play Progression
Once a concussion is identified and the athlete has been evaluated by a healthcare provider, the NFHS follows a graduated return-to-play protocol with six steps. Each step takes a minimum of 24 hours, and the athlete only advances if no new symptoms appear.
- Step 1: Return to regular daily activities like school, with healthcare provider clearance to begin the progression.
- Step 2: Light aerobic activity only, such as 5 to 10 minutes on a stationary bike or light jogging. No weight lifting.
- Step 3: Moderate activity that increases heart rate with body or head movement, including moderate jogging, brief running, and reduced weightlifting.
- Step 4: Heavy non-contact activity, including sprinting, full weightlifting routines, and sport-specific drills without contact.
- Step 5: Full practice with contact, in a controlled setting.
- Step 6: Return to competition.
If symptoms return at any step, the athlete drops back to the previous level and waits at least 24 hours before trying again. This means the fastest possible timeline from clearance to competition is about six days, but many athletes take longer. Parents and coaches are expected to monitor for symptoms after each day’s activity, not just during it. Symptoms that show up later in the evening or the next morning count.
The entire system is designed around a simple idea: concussion identification in high school sports is everyone’s job. Coaches watch for signs on the field, parents watch for changes at home, teammates speak up when something looks wrong, and the athlete reports what they feel honestly. The NFHS framework puts all of those observations together and errs on the side of caution every time.