Form At18 - Post Head Injury/concussion Initial Return To Participation


Florida High School Athletic Association
Revised 09/13
Post Head Injury/Concussion Initial Return to Participation
(Page 1 of 2)
This form must be completed for any student-athlete that has sustained a sports-related concussion and must be kept on file at the student-athlete’s school.
Athlete Name: ________________________________________ DOB: _____/_____/________ Injury Date: _____/_____/________
Sport: ___________________________ School: _________________________________ Level (Varsity. JV, etc.): _______________
I (treating physician) certify that the above listed athlete has been evaluated for a concussive head injury, and currently is/has:
(All Boxes MUST be checked before proceeding)
Normal neurological exam
Returned to normal classroom activity
Off medications related to this concussion
Neuropsychological testing (as available) has returned to baseline
The athlete named above is cleared to begin a graded return to play protocol (outline below) under the supervision of an athletic
trainer, coach or other health care professional as of the date indicated below. If the athlete experiences a return of any of his/
her concussion symptoms while attempting a graded return to play, the athlete is instructed to stop play immediately and notify
a parent, licensed athletic trainer or coach.
Physician Name: _______________________________ Signature/Degree: _______________________________________________
Phone: _____________________________ Fax: _____________________________ Today’s Date: ___________________________
Graded Return to Play Protocol
Each step, beginning with step 2, should take at least 24 hours to complete. If the athlete experiences a return of any concussion
symptoms they must immediately stop activity, wait at least 24 hours or until asymptomatic, and drop back to the previous asymptomatic
level. This protocol must be performed under supervision, please initial and date the box next to each completed step
Once the athlete has completed full practice i.e. stage 5, please sign and date below and return this form to the athlete’s physician (MD/
DO) for review and request the physician complete the return to competition form for the athlete to resume full activity.
Rehabilitation stage
Functional exercise at each stage
Date completed
1. No Activity
Rest; physical and cognitive
Noted above
Signed above
2. Light aerobic
Walking, swimming, stationary
Increased heart rate
bike, HR<70% maximum; no
weight training
3. Sport-specific
Non-contact drills
Add movement
4. Non-contact training
Complex (non-contact) drills/prac-
Exercise, coordination and
cognitive load
5. Full contact practice
Full contact practice
Restore confidence and
simulate game situations
6. Return to full activity
After completion of the steps above; Form AT18, Page 2 must be com-
Return to competition
pleted by physician
I attest the above named athlete has completed the graded return to play protocol as dated above.
Athletic Trainer / Coach
Name: _______________________________________________________ AT License Number: ______________________Phone: ____________________________
(If coach) AD/Principal Name: ___________________________________ School: _________________________________Phone: ____________________________
Athletic Trainer / Coach
Physician Reviewed:
Signature: _______________________________________________________ Date:
Athlete Signature: ________________________________________________ Date:
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