Sample Medical Concussion Clearance Form

Tools & Resources

Description

The Medical Concussion Clearance Form is for students who have completed Stage 4b of the Concussion Return to School Plan for Return to Learning (RTL) and Stage 4 of the Concussion Return to School Plan for Return to Physical Activity (RTPA). The student must be medically cleared by a medical doctor/nurse practitioner prior to moving on to full participation in non-contact physical activities and full contact practices (RTPA Stage 5).

Student Name:

Date:

I have examined this student and confirm they are medically cleared to participate in the following activities:

Full participation in Physical Education classes

Full participation in Intramural physical activities (non-contact)

Full participation in non-contact Interschool Sports (practices and competition)

Full-contact training/practice in contact Interschool Sports

Other comments:

Medical Doctor/Nurse Practitioner

In rural or northern regions, the Medical Clearance Form may be completed by a nurse with pre-arranged access to a medical doctor or nurse practitioner. Forms completed by other licensed healthcare professionals should not be otherwise accepted.

Name:

Signature:

Date:

A student who has received Medical Clearance and has a recurrence of symptoms or new symptoms appear, must immediately remove themselves from play, inform their parent/guardian/teacher/coach, and return to medical doctor or nurse practitioner for Medical Clearance reassessment before returning to physical activity.

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