Safe Re-opening of Schools Supports:

for the reopening of schools Ophea will continue to prioritize student safety and provide standards that will meet education's changing needs.

Sample Fainting Episode Form

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