Sample Medical Concussion Clearance Form

The Medical Concussion Clearance Form is for students who have completed Stage 4b of the Concussion Management Plan for Return to School (RTS) and Stage 4 of the Concussion Management 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.