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OCDSB 909 Documentation for Diagnosed Concussion Appendix E PR.561.SCO OCDSB 909: Documentation for a Diagnosed Concussion – Return to Learn/Return to Physical Activity Plan The Return to Learn/Return to Physical Activity Plan is a combined approach. Step 2a - Return to Learn must be completed prior to the student returning to physical activity. Each step must take a minimum of 24 hours (Note: Step 2b – Return to Learn and Step 2 – Return to Physical Activity occur concurrently). Step 1 – Return to Learn/Return to Physical Activity  Completed at home.  Cognitive Rest – includes limiting activities that require concentration and attention (e.g., reading, texting, television, computer, video/electronic games).  Physical Rest – includes restricting recreational/leisure and competitive physical activities. My child has completed Step 1 of the Return to Learn/Return to Physical Activity Plan (cognitive  symptoms have shown improvement and physical rest at home) and his/her . My child will proceed to Step 2a – Return to Learn. My child has completed Step 1 of the Return to Learn/Return to Physical Activity Plan (cognitive  symptom free and physical rest at home) and is . My child will proceed directly to Step 2b – Return to Learn and Step 2 – Return to Physical Activity. Parent/Guardian signature: ________________________________ Date: _____________________ Comments: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ OCDSB 909 If at any time during the following steps symptoms return, please refer to the “Return of Symptoms” section on page 3 of this form. Step 2a – Return to Learn  Student returns to school.  Requires individualized classroom strategies and/or approaches which gradually increase cognitive activity.  Physical rest– includes restricting recreational/leisure and competitive physical activities. symptom free My child has been receiving individualized classroom strategies and/or approaches and is .  My child will proceed to Step 2b – Return to Learn and Step 2 – Return to Physical Activity. Parent/Guardian signature: ________________________________ Date: _____________________ Comments: __________________________________________________________________________ __________________________________________________________________________ Step 2b – Return to Learn  Student returns to regular learning activities at school. Step 2 – Return to Physical Activity  Student can participate in individual light aerobic physical activity only.  Student continues with regular learning activities. My child is symptom free after participating in light aerobic physical activity. My child will proceed  to Step 3 – Return to Physical Activity. Appendix E will be returned to the teacher to record progress through Steps 3 and 4.  Parent/Guardian signature: ________________________________ Date: _____________________ Comments: __________________________________________________________________________ __________________________________________________________________________ Step 3 – Return to Physical Activity  Student may begin individual sport-specific physical activity only. Step 4 – Return to Physical Activity  Student may begin activities where there is no body contact (e.g., dance, badminton); light resistance/weight training; non-contact practice; and non-contact sport-specific drills. OCDSB 909 Student has successfully completed Steps 3 and 4 and is symptom free.  Appendix E will be returned to parent/guardian to obtain medical doctor/nurse practitioner  diagnosisand signature. Teacher signature: _________________________________________ Medical Examination I, _______________________________ (medical doctor/nurse practitioner name) have examined  _______________________________ (student name) and confirm he/she continues to be symptom free and is able to return to regular physical education class/intramural activities/interschool activities in non-contact sports and full training/practices for contact sports. Medical Doctor/Nurse Practitioner Signature: ____________________________________ Date: _____________________ Comments: __________________________________________________________________________ __________________________________________________________________________ ________________________________________________________________________________________ Step 5 – Return to Physical Activity  Student may resume regular physical education/intramural activities/interschool activities in non-contact sports and full training/practices for contact sports. Step 6 – Return to Physical Activity  Student may resume full participation in contact sports with no restrictions. Return of Symptoms My child has experienced a return of concussion signs and/or symptoms and has been examined  by a medical doctor/nurse practitioner, who has advised a return to:  Step __________ of the Return to Learn/Return to Physical Activity Plan Parent/Guardian signature: ________________________________ Date: _____________________ Comments: ________________________________________________________________________________________ ______________________________________________________________________________________ Freedom of Information Notice The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act and its regulations. This information is protected under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and will be utilized only for the purpose of managing student learning and well-being.Access to this information will be limited to those who have an administrative need, to the student to whom the information relates and the parent(s)/guardian (s) of a student who is under 18 years of age.Any questions with respect to this information should be directed to the school principal. OCDSB 909