Sample Fainting Episode Form

Tools & Resources

Description

This sample form is intended to serve as a guide for stakeholders to create a form that aligns with the policies and procedures in their respective school division/school.

The Fainting Episode Form must be completed by the student’s parent/guardian and returned to the school administrator/designate.

Name of Student:

Name of Teacher:

As a result of a fainting episode, my child was seen by a medical doctor.

Results of Medical Examination

My child/ward has been examined by a doctor who determined that a cardiac assessment was not necessary or required.

My child/ward has been examined by a doctor. A cardiac assessment was completed, and no rhythm disorders were diagnosed. My child/ward may resume full participation in physical activity with no restrictions.

My child/ward has been examined by a doctor. A cardiac assessment was completed, and a rhythm disorder was diagnosed. My child/ward therefore must begin a medically supervised return to physical activity plan. Refer to comments below and/or attached physician’s information.

Parent/Guardian signature:

Date:

Comments:

Physician’s input attached:

Yes

No

Attached Resource

Jun. 03, 2019

Sample Sudden Arrhythmia Death Syndrome Parent/Guardian Letter

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