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OCDSB 908 Appendix E Concussion Medical Assessment FormAppendix E: OCDSB 908 Concussion Medical Assessment Form Student Name: Date: The student must be assessed as soon as possible by a medical doctor or nurse practitioner. In Canada, only medical doctors and nurse practitioners are qualified to provide a concussion diagnosis. In rural or northern regions, a nurse with pre-arranged access to a medical doctor or nurse practitioner may be used to assess the suspected concussion. Prior to returning to school, the parents/guardians must inform the school principal of the results of the medical assessment. Results of the Medical Assessment My child/ward has been assessed and a concussion has not been diagnosed and therefore may resume full participation in learning and physical activity without any restrictions. My child/ward has been assessed and a concussion has been diagnosed and therefore must begin a medically supervised, individualized, and gradual Return to School (RTS) and Return to Physical Activity (RTPA) Plan. M My child/ward has been assessed and a concussion has not been diagnosed but the assessment led to the following diagnosis and recommendations: Comments: Medical doctor/nurse practitioner Name: Medical doctor/nurse practitioner​ ​Phone Number: Parent/Guardian Signature: Date: The personal information on this form is collected under the authority of the Education Act (RSO.1990 c.E.2) ss. 58.5, 265 and 266 as amended, and in accordance with the Municipal Freedom of Information and Protection of Privacy Act (RSO.1990 c.M56), as amended. It will be used for student and education related purposes, such as administration, communication, and data reporting. In addition, the information may be used or disclosed to comply with legislation, for compelling circumstances affecting the health and safety or discipline, as required in circumstances related to law enforcement matters, and with third parties in accordance with established service agreements or in accordance with any other Act. Questions or concerns should be directed to the school principal or the District's Freedom of Information Coordinator, Ottawa-Carleton District School Board, 133 Greenbank Road, Ottawa, Ontario K2H 6L3, Telephone 613-596-8211, ext. 8607. OCDSB 908 (June 2020)Page 1