and total length-of-care, respectively. Multivariable Cox proportional hazards modeling was used to assess the effect of Cognitive Symptom Ratio (CSR), defined as cognitive symptom score divided by Post-Concussion Symptom Scale (PCSS) score, on RTL duration.RESULTS: Of 653 athletes evaluated within 5 days of their concussion, 343 patients were included in the final cohort. Athletes reported a median initial PCSS score of 21 (IQR 6-37) and a median cognitive symptom score of 4 (IQR 0-9). Most patients endorsed some degree of "difficulty concentrating" (n = 212, 61.3%). Median CSR was 0.18 (IQR 0.00-0.27). On multivariable regression analysis, higher CSR was associated with prolonged RTL duration (HR 0.30, 95% CI 0.13-0.69, p = .004). When initial PCSS was added to the model, the previously significant association between CSR and RTL was no longer significant (HR 0.67, 95% CI 0.29-1.59, p = .367). When dichotomized based on frequency distribution, a higher proportion of low CSR patients achieved RTL by 7 days post-injury (82.2% vs. 69.9%, p = .007), a difference not seen at 14 days (92.2% vs. 87.3%, p = .133).CONCLUSIONS: Acute cognitive symptom scores can predict who may be at increased risk for prolonged RTL and which patients with normal PCSS scores may experience difficulties once resuming school activities.