Sample School Concussion Management Form (Return to School Plan)

The Return to Learning (RTL) and Return to Physical Activity (RTPA) Plans have been developed in partnership with Parachute and are based on the most recent research and recommendations of the expert scientific community on concussion, that is the Canadian Guidelines on Concussion in Sport, July 2017 and the Berlin Consensus Statement on Concussion in Sport, October 2016.

The RTL and RTPA plans are inter-related however, they are not interdependent. A student’s progress through the stages of RTL is independent from their progression through the RTPA stages. Different students will progress at different rates.

Before using the School Concussion Management Form (Return to School Plan), consult the General Procedures and the Instructions for the School Concussion Management Form (Return to School Plan).

The Sample School Concussion Management Form (Return to School Plan) derives from stages 3a to 4b of the Concussion Return to School Plan for Return to Learning and the stages of 3 to 6 of the Concussion Return to School Plan for Return to Physical Activity.

Name:
Date:

Return to Learning (RTL)

Stage 3a

School Responsibility

The student has demonstrated they can tolerate up to a half day of cognitive activity.
The School Concussion Management Form (Return to School Plan) is sent home to parents/guardians.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours.
The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner.
The School Concussion Management Form (Return to School Plan) is sent back to school.
Parent/Guardian Signature:
Date:
Comments:

Stage 3b

  • The student continues attending school half time with gradual increase in school attendance time, increased school work and a decrease in the adaptation of learning strategies and/or approaches.
    • Activities permitted if tolerated by student:
      • Activities from previous stage
      • School work for 4-5 hours per day, in smaller chunks (for example, 2-4 days of school/week)
      • Homework – up to 30 minutes per day
      • Decrease adaptation of learning strategies and/or approaches
      • Classroom testing with accommodations.
    • Activities that are not permitted at this stage:
      • Standardized tests/exams

School Responsibility

The student has demonstrated they can tolerate up to 4-5 hours of the cognitive activities listed.
The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours.
The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner.
The School Concussion Management Form (Return to School Plan) is sent back to school.
Parent/Guardian Signature:
Date:
Comments:

Stage 4a

  • Full day school, minimal adaptation of learning strategies and/or approaches
  • Nearly normal workload.
    • Activities permitted if tolerated by student:
      • Activities from previous stage
      • Nearly normal cognitive activities
      • Routine school work as tolerated
      • Minimal adaptation of learning strategies and/or approaches
        • Start to eliminate adaptation of learning strategies and/or approaches
        • Increase homework to 60 minutes per day
        • Limit routine testing to one test per day with accommodations (for example, supports - such as more time)
    • Activities that are not permitted at this stage:
      • Standardized tests/exams

School Responsibility

The student has demonstrated they can tolerate a full day of school and a nearly normal workload with minimal adaptation of learning strategies and/or approaches.
The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours.
The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner.
The School Concussion Management Form (Return to School Plan) is sent back to school.
Parent/Guardian Signature:
Date:
Comments:

Stage 4b

  • At school: full day, without adaptation of learning strategies and/or approaches
    • Activities permitted if tolerated by Student:
      • Normal cognitive activities
      • Routine school work
      • Full curriculum load (attend all classes, all homework, tests)
      • Standardized tests/exams
      • Full extracurricular involvement (non-sport/non-physical activity, for example, debating club, drama club, chess club)

School Responsibility

The student has demonstrated they can tolerate a full day of school without adaptation of learning strategies and/or approaches
The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours.
The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner.
Parent/Guardian Signature:
Date:
Comments:

Return to Physical Activity (RTPA)

Stage 3

  • Simple locomotor activities/sport-specific exercise to add movement.
    • Activities permitted if tolerated by student:
      • Activities from previous stage (20-30 minutes walking/stationary cycling/elliptical/recreational dancing at a moderate pace)
      • Simple individual drills (for example, running/throwing drills, skating drills in hockey, shooting drills in basketball) in predictable and controlled environments with no risk of re-injury
      • Restricted recess activities (for example, walking)
    • Activities that are not permitted at this stage:
      • Full participation in physical education or Daily Physical Activity
      • Participation in intramurals
      • Full participation in interschool practices
      • Interschool competitions
      • Resistance or weight training
      • Body contact or head impact activities (for example, heading a soccer ball)
      • Jarring motions (for example, high speed stops, hitting a baseball with a bat)

School Responsibility

The student has demonstrated they can tolerate simple individual drills/sport-specific drills as listed in permitted activities.
The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours.
The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner.
The School Concussion Management Form (Return to School Plan) is sent back to school.
Parent/Guardian Signature:
Date:
Comments:

Stage 4

  • Progressively increase physical activity. Non-contact training drills to add coordination and increased thinking.
    • Activities permitted if tolerated by student:
      • Activities from previous stage
      • More complex training drills (for example, passing drills in soccer and hockey)
      • Physical activity with no body contact (for example, dance, badminton)
      • Participation in practices for non-contact interschool sports (no contact)
      • Progressive resistance training may be started
      • Recess – physical activity running/games with no body contact
      • Daily Physical Activity
    • Activities that are not permitted at this stage:
      • Full participation in physical education
      • Participation in intramurals
      • Body contact or head impact activities (for example, heading a soccer ball)
      • Participation in interschool contact sport practices, or interschool games/competitions (non-contact and contact)

School Responsibility

The student has completed the activities in Stage 4 as applicable.
The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian.
A Concussion Medical Clearance Form is sent home to parent/guardian.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours.
The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner.
The School Concussion Management Form (Return to School Plan) is sent back to school.
Parent/Guardian Signature:
Date:
Comments:
  • Before progressing to Stage 5, the student must:
    • have completed Stage 4a and 4b of RTL (full day at school without adaptation of learning strategies and/or approaches);
    • have completed Stage 4 of RTPA and be symptom-free; and
    • obtain a signed medical clearance from a medical doctor or nurse practitioner.
  • Please Note: Premature return to contact sports (full practice and game play) may cause a significant setback in recovery.

Stage 5

  • Following medical clearance, full participation in all non-contact physical activities (that is, non-intentional body contact) and full contact training/practice in contact sports.
    • Activities permitted if tolerated by student:
      • Physical Education
      • Intramural programs
      • Full contact training/practice in contact interschool sports
    • Activities that are not permitted at this stage:
      • Competition (for example, games, meets, events) that involves body contact

School Responsibility

The student has successfully completed the applicable physical activities in Stage 5.
The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms or new symptoms.
The student has exhibited or reported a return of symptoms or new symptoms and must return to medical doctor or nurse practitioner for a Medical Clearance reassessment.
The School Concussion Management Form (Return to School Plan) is sent back to school.
Parent/Guardian Signature:
Date:
Comments:

Stage 6

  • Unrestricted return to contact sports. Full participation in contact sports games/competitions

School Responsibility

The student has successfully completed full participation in contact sports.
The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian.
School Initial (for example, collaborative team lead/designate):
Date:

Home Responsibility

The student has not exhibited or reported a return of symptoms or new symptoms.
The student has exhibited or reported a return of symptoms or new symptoms and must return to medical doctor or nurse practitioner for a Medical Clearance reassessment.
The School Concussion Management Form (Return to School Plan) is sent back to school for documentation purposes.
Parent/Guardian Signature:
Date:
Comments: