Instructions for the Home Concussion Management Form (Return to School Plan)

  • Review the activities (permitted and not permitted) at each stage prior to beginning the plan.
  • Check the boxes at the completion of each stage to record student’s progress through the stages.
  • A student may progress through the Return to Learning (RTL) stages at a faster or slower rate than the Return to Physical Activity (RTPA) stages.
  • When the student has successfully completed stages 1 and 2 of the Concussion Return to School Plan for RTL and RTPA, parent(s)/guardian(s) must sign and date this form.
  • Communicate to the school principal/designate that the student is ready to begin the school portion of the RTL and RTPA plan.