Medical Clearance To Return To Play Form - Michigan Department Of Community Health printable pdf download

Michigan Department of Community Health

State of Michigan Governor Rick Snyder

MDCH Director James K. Haveman

MEDICAL CLEARANCE TO RETURN TO PLAY

The State of Michigan requires that a youth athlete, who has been removed from physical

participation in an athletic activity, shall not return to physical activity until he or she has been evaluated

by an appropriate health professional and receives written clearance

from that health professional

authorizing the youth athlete’s return to physical participation in the athletic activity. This form is to be

used after an athlete has been removed from an athletic activity due to a suspected concussion

Student Name: ________________________________________________ DOB: _____/______/_____

School: _______________________________________________ Date of Injury: _____/______/_____

Nature and extent of injury: ______________________________________________________________

_____________________________________________________________________________________

Medical clearance should only be provided after a graduated return to play plan

has been completed

and the student has been symptom free at all stages. The student must be completely symptom free at

rest and during exertion prior to returning to full participation in physical activity.

If concussion diagnosed, date student completed graduated return to play plan without recurrent

symptoms: _____/______/______

Print Health Professional Name: ___________________________________Title:___________________

Note: An “Appropriate health professional” means a health professional who is licensed or otherwise authorized to engage in a health

profession and whose scope of practice within that health profession includes the recognition, treatment, and management of concussions.

Address: _________________________________________ Phone Number: __________________

I HEREBY AUTHORIZE THE ABOVE NAMED STUDENT TO RETURN TO ATHLETIC ACTIVITY FOR FULL

PARTICIPATION WITHOUT RESTRICTION.

Signature: ____________________________________________________Date:____/_____/_____

The organizing entity shall maintain this written clearance in a permanent file for the duration of that youth

athlete’s participation in athletic activity sponsored by or operated under the auspices of that organizing entity or

until the youth athlete is 18 years of age.

A “Concussion” is a type of traumatic brain injury as recognized by the Centers for Disease Control and Prevention.

A concussion may cause a change in a person’s mental status at the time of the injury including, but not limited to

feeling dazed, disoriented, or confused, and may or may not include a loss of consciousness. A concussion may be

caused by any type of accident or injury including, but not limited to the following: a fall, blow, bump or jolt to the

head or body, the shaking or spinning of the head or body, or the acceleration and deceleration of the head.

Return to play guidelines may be found at:

and

should only be administered by an appropriate health professional.

Medical Clearance To Return To Play Form - Michigan Department Of Community Health