Post Head Injury/concussion Initial Return To Participation - Florida High School Athletic Association


Florida High School Athletic Association
Created 06/12
Post Head Injury/Concussion Initial Return to Participation
(Page 1 of 2)
This completed form must be kept on file at the student-athlete’s school.
Student Name: _____________________________ School: _________________________________ DOB: _____/_____/________
Sport: ___________________________________ Date of Injury: _____/_____/________
I certify that the above listed student-athlete has been evaluated for a concussive head injury, is currently asymptomatic with a normal
neurological examination, off of all medications related to this concussive injury and (as available) all computerized neurological tests
have returned to baseline (Zurich Stage 1). The student-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.
Date Cleared for Graded Return to Play Protocol: _____/_____/________
If the student-athlete experiences a return of any of his/her concussion symptoms while attempting a graded return to play, the
student-athlete is instructed to stop play immediately and notify a parent, licensed athletic trainer or coach.
Physician Name: ________________________________ Signature/Degree: _____________________________________________
Phone: (_______) ____________________ Fax: (_______) ____________________ Date: _____/_____/________
Graded Return to Play Protocol
Each step 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 asymptomat-
ic 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 4), please sign and date below and return this form to the student-athlete’s phy-
sician (MD/DO) for review and request the physician complete the return to competition form for the athlete to resume full activity.
Functional exercise at each
Rehabilitation stage
Date completed
1. Light aerobic
Walking, swimming, stationary
Increased heart rate
bike, HR<70% maximum
2. Sport-specific
Non-contact drills
Add movement
3. Non-contact training Complex (non-contact) drills/
Exercise, coordination
and cognitive load
4. Full contact practice Full contact practice
Restore confidence and
simulate game situations
I attest the above-named student-athlete has completed the graded return to play protocol as dated above.
Athletic Trainer/Coach Name: ______________________________ Signature: ______________________________ Date: _____/_____/________
(if athletic trainer) AT License Number: _______________________ Phone: (_______) _________________
(if coach) AD/Principal Name: _____________________________ School: _________________________ Phone: (_______) ________________
Student-Athlete Signature: _________________________________ Date: _____/_____/________
Physician Reviewed:
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