Medical Clearance To Return To Play After Suspected Concussion Form

MEDICAL CLEARANCE TO RETURN TO PLAY AFTER SUSPECTED CONCUSSION

he State of Ohio 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 a licensed health

care professional (LHCP) and receives written clearance from that LHCP 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.

Youth Athlete Name:_____________________________________________DOB: ____ / ____ /____.

School/Organization: ______________________________________Date of Injury: ____ / ____ /____.

For the concussed athlete, medical clearance will only be provided with completion of a graduated return

to play plan. The youth athlete must be completely symptom free and meet criteria for returning to play as

defined in the approved guidelines.

Date youth athlete completed graduated return to play without recurrent symptoms:____ / ____ /____.

I HEREBY AUTHORIZE THE ABOVE NAMED YOUTH ATHLETE FOR RETURN TO PLAY TO YOUTH SPORTS

ACTIVITY

Licensed Health Care Professional signature:__________________________ . Date: ____ / ____ /____.

Print Name: _________________________________________________________________________.

Check one

MD/DO

DACNB/DACBSP/CCSP* Other: ______________________________________.

Address: ___________________________________________________________________________ .

Name of MD/DO providing consultation/coordination/supervision/referral (if not person completing this

form; please print): ___________________________________________________________________ .

Guidelines refer to the most recent Consensus Statement on Concussion in Sport (currently the 4th International Conference

on Concussion in Sport held in Zurich, November 2012) or with nationally accepted standards and guidelines consistent with

that statement.

*Physicians (M.D. or D.O.) and Diplomates in either Chiropractic Neurology or Chiropractic Sports Medicine and Certified

Chiropractic Sports Physicians who are listed in the American Chiropractic Board of Sports Physicians (ACBSP) Concussion

Registry meet the recommended standards of care and are able to independently clear youth athletes to return to play.

This form may be reproduced and can be found on the Ohio Department of Health’ s website at:

2015

Medical Clearance To Return To Play After Suspected Concussion Form - 2015