Appendix F: Documentation for Medical Clearance

This form is to be provided to students who have completed the Return to School (RTS) Stage 4b and Return to Physical Activity (RTPA) Stage 4. Consult the School Concussion Management Plan below. 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.

 

Note: Forms completed by other licensed healthcare professionals will not be otherwise accepted.

 

·   Full participation in Physical Education classes

·   Full participation in Intramural physical activities (non-contact)

·   Full participation in non-contact Interschool Sports (practices and competition)

Medical Doctor/Nurse Practitioner

 

Name:
Signature:
Date:

What if symptoms recur? 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.

 

The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act and its regulations. This information is protected under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and will be utilized only for the purpose of managing student learning and well-being. Access to this information will be limited to those who have an administrative need, to the student to whom the information relates and the parent(s)/guardian (s) of a student who is under 18 years of age. Any questions with respect to this information should be directed to the school principal.

In accordance with the Municipal Freedom of Information and Protection of Privacy Act this information will be used solely to assess the student’s Return to Learn and Return to   Physical Activity . It will be retained in the Ontario Student Record [OSR] for one year after the student graduates or transfers out of the school. The Ministry of Education may also request school reports on concussion activity. If you have any questions or concerns about the collection of information on this form, please contact the school principal.

 

Reproduced and adapted with permission from Ophea, [Ontario Physical Education Safety Guidelines, 2018]

 

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