Sample Medical Concussion Clearance Form
This sample tool is intended to be signed by a medical doctor or nurse practitioner to indicate a student is medically cleared to progress from Return to Physical Activity - Stage 3 to Return to Physical Activity - Stage 4.
Student Name:
Date:
I have examined this student and confirm that they are medically cleared to participate in the following activities:
- Full participation in learning activities (Return to Learn – Stage 4)
- Participation in physical activities that include skill progression/training drills and activities with low-risk of body contact (Return to Physical Activity – Stage 4)
Medical Doctor or Nurse Practitioner
Name:
Signature:
Date:
Comments: