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

AT18

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)

Asymptomatic

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

Objective

Date completed

Initials

1. No Activity

Rest; physical and cognitive

Recovery

Noted above

Signed above

2. Light aerobic

Walking, swimming, stationary

Increased heart rate

exercise

bike, HR<70% maximum; no

weight training

3. Sport-specific

Non-contact drills

Add movement

exercise

4. Non-contact training

Complex (non-contact) drills/prac-

Exercise, coordination and

tice

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

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