Form C-3 - Halton Monitoring/medical Examination Form printable pdf download

Form C-3

Halton Monitoring/Medical Examination Form

This form is provided to the parent/guardian, in conjunction with Tool to Identify a Suspected Concussion, Form C-2.

_________________________ (student/athlete name) __________________(date), sustained a blow to the

head, face or neck or a blow to the body that transmits a force to the head, and as a result may have suffered a

concussion.

Results of initial assessment using Tool to Identify a Suspected Concussion:

NO SIGNS OR SYMPTOMS OBSERVED AT TIME OF INCIDENT.

However, signs or symptoms can appear immediately after the injury or may take hours or days to

emerge. Your child/ward is not to participate in physical activity and is to be monitored for a 24 hour

period. While at home parent/guardian is to monitor their child/ward using the Tool to Identify a

Suspected Concussion. School Staff will monitor the student/athlete while at school.

Actions: If no signs/symptoms occur during the monitoring period, parent/guardian is to complete the

following Results of Monitoring section prior to their child/ward returning to school.

Results of Monitoring

As the parent/guardian, my child/ward has been observed for the 24 hour period, and no

signs/symptoms have been observed.

Parent/Guardian signature: ________________________________ Date: _____________________

Comments:

_____________________________________________________________________________________

SIGNS OR SYMPTOMS OBSERVED:

______ AT TIME OF INCIDENT

______DURING THE 24 HOUR MONITORING PERIOD

For the signs and/or symptoms observed at the time of incident/during the 24 hour monitoring period,

refer to the Tool to Identify a Suspected Concussion (Form C-2) provided by teacher/coach/supervisor

Actions: Your child/ward must be seen by a medical doctor or nurse practitioner as soon as possible with the

Results of Medical Examination form (below) returned to the school principal after medical examination.

Results of Medical Examination

My child/ward has been examined and no concussion has been diagnosed and therefore may resume

full participation in learning and physical activity with no restrictions.

My child/ward has been examined and a concussion has been diagnosed and therefore must begin a

medically supervised, individualized and gradual Return to Learn/Return to Physical Activity Plan (Form C-4)

Parent/Guardian signature: ________________________________

Date: _____________________

Comments:

_____________________________________________________________________________________

HCDSB Concussion Protocol Monitoring/Medical Examination Form

Adapted from OPHEA Safety Guidelines

Copied to OSR once completed

Form C-3

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Form C-3 - Halton Monitoring/medical Examination Form