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Sample Medical Concussion Clearance Form

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.