During Stages 1, 2, or 3 (prior to medical clearance) it is common and ok for a student’s symptoms to return or worsen mildly and briefly, as long as these symptoms do not last for more than an hour or they cannot tolerate them. If symptoms persist for more than an hour:

For Return to Learn: the student should take a break and the activities should be adapted.

For Return to Physical Activity: the student should stop the activity and try again the next day at the same stage.

Student Name:

Date:

Return to Learn

Stage 1: Activities of Daily Living and Relative Rest (at home)

Goal: Take more rest, if needed, in first 1 – 2 days. Encourage gentle activity. Avoid sports.

Stage 1- Activities of Daily Living and Relative Rest are the same for Return to Learn (RTL) and Return to Physical Activity (RTPA). These are done at home, should start at the same time and should not take more than 1-2 days.

In Stage 1, resting completely for more than two days is not suggested and a complete absence from the school environment for more than one week is not recommended.

Examples of activities at this stage:

·   Moving around the home and light walking

·   Short games/activities (e.g., puzzles, board games, drawing, crafts)

·   Social interaction (e.g., with family, friends)

·   Minimize screen time (e.g., phone, TV, computer/tablet)

Student is ready to progress to Stage 2 RTL and RTPA after a maximum of 24-48 hours. A student’s symptoms maypare worsen mildly and briefly at this stage.

Parents/Guardians

My child/ward will be returning to school at RTL and RTPA Stage 2.

Note: If your child/ward is not returning to school after Stage 1 they should complete the activities from RTL and RTPA – Stage 2 at home and return to school when they are ready to progress to RTL and RTPA – Stage 3.

Signature of Parents/Guardians:

Date:

Comments:

Stage 2: School Activities (as tolerated) (completed at home or at school)

Goal: Increase tolerance to cognitive activities and school environments (as appropriate).

Examples of activities at this stage:

·   Gradual reintroduction of light cognitive activities (e.g., reading, short periods of schoolwork/ activities with frequent breaks) as tolerated.

·   Accommodations (e.g., access to breaks, additional time to complete work) may be required for cognitive activities and/or environmental factors (e.g., dim lighting).

·   Continue to prioritize social interactions (e.g., with peers and family); this is preferably done at school.

·   Start with shorter periods of screen time (e.g., phone, TV, computer/tablet) and build up as tolerated.

·   Avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Students can progress to RTL – Stage 3 when they can tolerate Stage 2 activities. It is ok for a student’s symptoms to worsen mildly and briefly at this stage.

School Tracking For students who completed RTL – Stage 2 at home:

Parents/Guardians

The student will be returning to school at RTL –Stage 3.

For students who completed RTL – Stage 2 at school:

Principal/Designate

The student is ready to progress to RTL – Stage 3.

Parents/Guardians

The student is ready to progress to RTL – Stage 3.

Signature of Principal/Designate:

Date:

Comments:

Signature of Parents/Guardians:

Date:

Comments:

Stage 3: Part Time or Full Time at School with Accommodations as needed and completed at school

Goal: Continue to increase tolerance of cognitive activities and the school environment. A gradual increase of time spent on activities and on the types of activities in which students can participate. A gradual reduction of concussion-related accommodations at school.

Examples of activities at this stage:

·   Continued progression of cognitive activities (e.g., schoolwork) and exposure to the school environment (e.g., interacting with family and friends, exposure to noise/lighting) as tolerated

·   Continued use of screened devices (as tolerated).

·   Avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Student can progress to RTL – Stage 4 when they can tolerate full days of cognitive activities and the school environment without accommodations for concussion.

School Tracking For student who completed RTL – Stage 3 at school:

Principal/Designate

The student is ready to progress to RTL – Stage 4

Parents/Guardians

The student is ready to progress to RTL – Stage 4

Signature of Principal/Designate:

Date:

Comments:

Signature of Parents/Guardians:

Date:

Comments:

Return to Physical Activity

Stage 2: Light- to Moderate-effort Aerobic Activity/Exercise (completed at home or at school)

Goal: Increase the heart rate and gradually increase the intensity of aerobic activities and exercises that can be done individually in a predictable and controlled environment with a low risk of inadvertent head impacts.

Examples of activities at this stage:

·   Gradual reintroduction of light aerobic activity/exercise (as tolerated) (e.g., low impact aerobics circuits, slow to medium pace movement)

·   Gradually increase the intensity of aerobic activity/exercise to moderate effort (e.g., fitness activities, walking/rolling/swimming at a pace that causes some increase in breathing/heart rate but not enough to prevent a student from carrying on a conversation comfortably)

·   May begin light resistance training (e.g., resistance bands, light weights in a controlled environment)

·   Activities should be supervised/monitored by parents/guardians, teacher/supervisor/coach

·   Avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Home/School Tracking Students can progress to RTPA – Stage 3 when they can tolerate Stage 2 activities. A student’s symptoms may worsen mildly and briefly at this stage.

For students who completed RTPA – Stage 2 at home:

Parents/Guardians

The student will be returning to school at RTPA – Stage 3.

For student who completed RTPA – Stage 2 at school:

Principal/Designate

The student is ready to progress to RTPA – Stage 3.

Parents/Guardians

The student is ready to progress to RTPA – Stage 3.

Signature of Principal/Designate:

Date:

Comments:

Signature of Parents/Guardians:

Date:

Comments:

Stage 3: Individual Movement Skills/Sport-specific Activities with Low Risk of Inadvertent Head Impact

Goal: Continue to increase the intensity of aerobic activities/exercise and introduce activity/sport-specific movements and changing directions.

Examples of activities at this stage:

·   Add individual movement skills/sport-specific activities (e.g., passing to a wall/partner, throwing/catching drills, individual sequence activities).

·   Activities should be supervised/monitored by parents/guardians or teacher/supervisor/ coach.

·   Activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Home/School Tracking A student can progress to RTPA – Stage 4 when they are symptom-free from concussion-related symptoms at rest and at full physical exertion, have completed the Return to Learn Stages, and receive written medical clearance from a physician or nurse practitioner.

Principal/Designate

The student is ready to progress to RTPA – Stage 4.

Parents/Guardians

The student is ready to progress to RTPA – Stage 4.

Written medical clearance form is attached.

 

Signature of Principal/Designate:

Date:

Comments:

Signature of Parents/Guardians:

Date:

Comments:

A student should not return to RTPA – Stage 4 (activities with risk of contact) until they have obtained written medical clearance from a physician/nurse practitioner.

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