Concussion Evaluation And Release To Play Form For Licensed Health Care Providers printable pdf download

CONCUSSION EVALUATION AND RELEASE TO PLAY FORM FOR LICENSED HEALTH CARE PROVIDERS

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(SECTION ONE: Completed by School Personnel)

Student Name: _______________________________________________

Date: ______________

Sport’s Team: _________________

Grade: __________

Number of Past Concussions: __________

Brief Description by School Personnel of How Injury Occurred and Why Concussion is Suspected:

__________________________________________________________

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(SECTION TWO: Completed by Licensed Health Care Provider)

Per Indiana Code 20-34-7, a student athlete who is suspected of suffering a concussion may not return

to play until the student athlete has been evaluated by a licensed health care provider trained in the

evaluation and management of concussions and head injuries, receives a written clearance to return to

play from the health care provider who evaluated the student athlete, and at least twenty-four (24)

hours have passed since the student athlete was removed from play.

Health Care Provider Name: ____________________________________________________________

License Number: ____________________

Licensing Board: _________________________________

I have evaluated the above mentioned student athlete and the student athlete is:

______ NOT cleared to participate in any sports-related activities (including gym class) until seen for a

follow-up exam

______ Cleared, as of today, to return to all activities, including sports, without restrictions

______ Cleared to return to all activities, including sports, without restrictions,

on the following date* - _______________

_____ Cleared to return to sports following the schedule below:

Step 1: May participate in light activity on the following date* - ____________________

(10 minutes on an exercise bike, walking, or light jogging; but no weight lifting, jumping or hard running)

Step 2: May participate in moderate activity on the following date* - __________________

(Moderate intensity activity on an exercise bike, jogging or weight lifting {reduced time and/or weight than normal})

Step 3: May participate in heavy; non-contact physical activity on the following date* -________

(Sprinting, running, high-intensity exercise bike, and weight lifting; but no contact sports)

Step 4: May return to practice and full contact in a controlled practice setting on the following

date* - _______________

Step 5: May return to full game play on the following date* - ______________

______ Other – please list:

* Please note that if signs and symptoms of a concussion occur, the student must return to the previous stage and

parents must contact the licensed health care provider for instructions.

_____________________________________________

__________________________

(Signature of Health Care Provider)

(Date)

Updated April 2016

Concussion Evaluation And Release To Play Form For Licensed Health Care Providers