Appendix E2: School Concussion Management - Return to School (RTS) and
Return to Physical Activity (RTPA) Plan

Appendix E2: School Concussion Management - Return to School (RTS) and

Return to Physical Activity (RTPA) Plan

This form is to be used by parents/guardians and the school Collaborative Team to communicate and track a student’s progress through the stages of the Return to School and Return to Physical Activity Plan following completion of Home Preparation for Return to School and Return to Physical Activity.
School Staff is asked to refer to Appendix E3 for the Student Return to School Reference Guide.
Each stage must take a minimum of 24 hours.
All steps must be followed.

General procedures for School Concussion Management – Return to School (RTS) and Return to Physical Activity (RTPA) Plan

· The Plan does not replace medical advice.

1.	The school part of the plan begins with a parent/guardian and principal or designate communicating information on:

· the school part of the RTS and RTPA Plan (Appendix E2);
· the Collaborative Team members and their role

2. A student conference will be established to determine the individualized RTS and RTPA Plan and to identify:

·	the RTS learning strategies and/or approaches required by the student based on the post-concussion symptoms

· the best way to provide opportunities for the permissible activities.

3. The need to report any return of symptoms to supervising staff/volunteer should be emphasized to the student and parent/guardian.
4. The stages of the General Procedures for School Concussion Management plan occur at school and where appropriate the RTPA part of the plan may occur during school activities or outside activities
5. For the student who is participating in activities outside of the school, communication is essential between the parent/guardian/student, activities supervisor and the collaborative team members.
6. Stages within the plan:

· Stages are not days – each stage must take a minimum of 24 hours
· The length of time needed to complete each stage will vary based on the student and the severity of the concussion.
· A student who has no symptoms when they return to school must progress through all of the RTS stages and RTPA stages and remain symptom free for a minimum of 24 hours in each stage prior to moving to the next stage.
· Completion of the plan may take 1-4 weeks.

7. The Collaborative Team will closely monitor student for the return of any concussion symptoms and/or deterioration of work habits and performance.
8. A student moves forward to the next stage when activities at the current stage are tolerated and the student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.

9. A student’s progression through the stages of RTS is independent from their progression through the RTPA stages.
10. Medical clearance by a doctor/nurse practitioner is required prior to beginning Stage 5 of RTPA (Documentation for Medical Clearance Appendix F).
11. Until a student has successfully completed all stages in the RTS plan they must not participate in the following physical activities where the risk of re-injury is possible:

· full participation in the physical education curricular program;
· intramural activities;
· full participation in non-contact interschool activities; or
· participation in practice for a contact sport.

12. Upon completion of the RTS and RTPA Plan, this form is returned to the principal or designate for filing in the OSR.

Return of Symptoms

The student and the parent/guardian will report any return of symptoms to supervising staff/volunteers

· During all stages of RTS and in Stages 1-4 of RTPA:

o if symptoms return or new symptoms appear, the student returns to previous stage for a minimum of 24 hours and only participates in activities that can be tolerated.

· After Medical Clearance, during stages 5 and 6 of RTPA:

o if symptoms return or new symptoms appear, the student must return to medical doctor/nurse practitioner to have the Medical Clearance re-assessed.

· During all stages of RTS and RTPA, if symptoms worsen over time, follow the school’s collaborative team procedures for contacting parents/guardians to inform them that the student needs a follow-up medical assessment.

Students requires a medical assessment for return/worsening symptoms
· When there is a return/worsening of symptoms the principal or designate contacts parent/guardian (or emergency contact) to inform of returned/worsened symptoms and the possible need for medical assessment on the same day.
· The collaborative team is to be informed and to follow the medical doctor/nurse
practitioner’s treatment recommendations.

Instructions: At each stage, this form will be exchanged between the school and home.
· Review the activities (permitted and not permitted) at each stage prior to beginning the Plan.
· School provides appropriate activities and documents student’s progress by checking ( ✔ ), dating, initialing completion of each stage and communicating information (form) to parent/guardian.
· Within each stage, parent/guardian completes, checks ( ✔ ), dates, and signs the student’s tolerance to those activities giving permission for the student to progress to the next stage and returns completed form to school.
· Principal or designate will inform all school staff when the student:

o is able to advance to the next stage
o must return to the previous stage
o must be medically assessed
o has completed the plan

School Concussion Management – Return to School (RTS) and Return to Physical Activity (RTPA) Plan

Return to School (RTS) Stages	Return to Physical Activityu (RTPA) Stages
Stage 3
RTS – Stage 3a Student begins with an initial length of time at school of 2 hours. The individual RTS Plan is developed by Collaborative Team following the student conference and assessment of the student’s individual needs determining possible strategies and/or approaches for student learning (refer to Appendix B: Return to Learn Approaches). Activities permitted if tolerated by the student · Activities from previous stage. · School work for up to 2 hours per day in smaller chucks (completed at school) working up to ½ day of cognitive activity. · Adaptation of learning strategies and/or approaches. Activities that are not permitted at this stage · Tests/exams · Homework · Music class · Assemblies · Field trips	RTPA – Stage 3 Simple locomotor activities/sport-specific exercise to add movement. Activities permitted if tolerated by student · Activities from previous stage (20 – 20 minutes walking/stationary cycling/elliptical/recreational dancing at a moderate pace). · Simple individual drills (e.g., 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 (e.g., walking. Activities that are not permitted at this stage · Full participation in physical education or DPA · Participation in intramurals · Full participation in interschool practices · Interschool competitions · Resistance or weight training · Body contact or head impact activities (e.g., heading a soccer ball) · Jarring motions (e.g., high speed stops, hitting a baseball with a bat)
School · Student has demonstrated they can tolerate up to a half day of cognitive activity. · E2 sent home to parent/guardian	School · Student has demonstrated they can tolerate simple individual drills/sports-specific drills as listed in permitted activities. · E2 sent home to parent/guardian.
School initials (e.g., collaborative team Lead/designate): ____________________ Date: _____________________________	School initials (e.g., collaborative team Lead/designate): ____________________ Date: _____________________________
Home · Student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms. · 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. · Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner. · Appendix E2 sent back to school. Parent(s)/Guardian(s) Signature: _________________________________ ___________________________________	Home · Student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms. · 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. · Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner. · Appendix E2 sent back to school. Parent(s)/Guardian(s) Signature: ___________________________________
Parent/Guardian: _____________________ Signature: ___________________________ Date: _______________________________ Comments: _________________________ ____________________________________	Parent/Guardian: _____________________ Signature: ___________________________ Date: _______________________________ Comments: _________________________ ____________________________________
RTS – Stage 3b Student continues attending school half time with gradual increase in school attendance. Gradual increase in 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 (e.g., 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 · Student has demonstrated they can tolerate up 4 – 5 hours of the cognitive activity. · E2 sent home to parent/guardian
School initials (e.g., collaborative team Lead/designate): ____________________ Date: _____________________________
Home · Student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms. · 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. · Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner. · Appendix E2 sent back to school. Parent/Guardian Signature: __________________________________	Home · Student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms. · 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. · Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner. · Appendix E2 sent back to school. Parent/Guardian Signature: ___________________________________
Parent/Guardian: _____________________ Signature: ___________________________ Date: _______________________________ Comments: _________________________ ____________________________________	Parent/Guardian: _____________________ Signature: ___________________________ Date: _______________________________ Comments: _________________________ ___________________________________
RTS Stage 4B	Stage 5
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 test/exams · Full extra curriculum involvement (non-sport/non-physical activity, (e.g., debating club, drama club, chess club) School · Student has demonstrated they can tolerate a full day of school without adaptation of learning strategies and/or approaches · Appendix E2 sent home to parent/guardian	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 (e.g., games, meets, events that involves body contact School · Student has successfully completed the applicable physical activities in RTPA Stage 5 · Appendix E2 sent home to parent/guardian School initials (e.g., collaborative team Lead/designate): ________________________________ Date: _____________________________
Parent/Guardian: _____________________ Signature: ___________________________ Date: _______________________________ Comments: _________________________ ____________________________________	Home · Student has not exhibited or reported a return of symptoms or new symptoms · If the student has exhibited or reported a return of symptoms or new symptoms, he/she must return to a medical doctor or nurse practitioner for Medical Clearance reassessment. · E2 sent back to school

Before progressing to RTPA Stage 5, the student must

· Have completed RTS Stage 4a and 4b (fully day at school without adaptation of learning strategies and/or approaches

· Have completed RTA Stage 4 and be symptom-free and

· Obtain a signed Medical Clearance from a medical doctor or a nurse practitioner (Appendix F)

Please Note: Premature return to contact sports (full practice and game play) may cause a significant setback in recovery.

School initials (e.g., collaborative team

Lead/designate): ____________________

Date: _____________________________

Parent/Guardian: _____________________

Signature: ___________________________

Date: _______________________________

Comments: _________________________

____________________________________

Home

· Student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.

· 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.

· Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner.

· Appendix E2 sent back to school.

Parent/Guardian Signature:

_______________________________

___________________________________

Parent/Guardian: _____________________

Signature: ___________________________

Date: _______________________________

Comments: _________________________

____________________________________

Stage 6
	RTPA – Stage 6 · Unrestricted return to contact sports full participation in contact sports, games/competitions School · Student has completed full participation in contact sports · E2 sent home to parent/guardian School initials (e.g., collaborative team Lead/designate): ____________________ Date: _____________________________
	Home · Student has not exhibited or reported a return of symptoms or new symptoms and has completed RTPA Plan. · Student has exhibited/reported a return of symptoms or new symptoms, then must return to a medical doctor or a nurse practitioner for Medical Clearance reassessment. · E2 sent back to school for documentation purposes
	Parent/Guardian: _____________________ Signature: ___________________________ Date: _______________________________ Comments: _________________________ ____________________________________

The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act and its regulation. 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 form Ophea, (Ontario Physical Education Safety Guidelines, 2018.

·	the school part of the RTS and RTPA Plan (Appendix E2);
·	the Collaborative Team members and their role

3.	The need to report any return of symptoms to supervising staff/volunteer should be emphasized to the student and parent/guardian.
4.	The stages of the General Procedures for School Concussion Management plan occur at school and where appropriate the RTPA part of the plan may occur during school activities or outside activities
5.	For the student who is participating in activities outside of the school, communication is essential between the parent/guardian/student, activities supervisor and the collaborative team members.

·	Stages are not days – each stage must take a minimum of 24 hours
·	The length of time needed to complete each stage will vary based on the student and the severity of the concussion.
·	A student who has no symptoms when they return to school must progress through all of the RTS stages and RTPA stages and remain symptom free for a minimum of 24 hours in each stage prior to moving to the next stage.

7.	The Collaborative Team will closely monitor student for the return of any concussion symptoms and/or deterioration of work habits and performance.
8.	A student moves forward to the next stage when activities at the current stage are tolerated and the student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.


9.	A student’s progression through the stages of RTS is independent from their progression through the RTPA stages.
10.	Medical clearance by a doctor/nurse practitioner is required prior to beginning Stage 5 of RTPA (Documentation for Medical Clearance Appendix F).
11.	Until a student has successfully completed all stages in the RTS plan they must not participate in the following physical activities where the risk of re-injury is possible:

·	full participation in the physical education curricular program;
·	intramural activities;
·	full participation in non-contact interschool activities; or
·	participation in practice for a contact sport.


Students requires a medical assessment for return/worsening symptoms
·	When there is a return/worsening of symptoms the principal or designate contacts parent/guardian (or emergency contact) to inform of returned/worsened symptoms and the possible need for medical assessment on the same day.

·	The collaborative team is to be informed and to follow the medical doctor/nurse
practitioner’s treatment recommendations.


Instructions: At each stage, this form will be exchanged between the school and home.
·	Review the activities (permitted and not permitted) at each stage prior to beginning the Plan.
·	School provides appropriate activities and documents student’s progress by checking ( ✔ ), dating, initialing completion of each stage and communicating information (form) to parent/guardian.
·	Within each stage, parent/guardian completes, checks ( ✔ ), dates, and signs the student’s tolerance to those activities giving permission for the student to progress to the next stage and returns completed form to school.

o	is able to advance to the next stage
o	must return to the previous stage
o	must be medically assessed
o	has completed the plan