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OCDSB 970 Appendix K School Management FormAppendix K: OCDSB 970 School Concussion Management Form This form derives from stages 3a to 4b of the ​Concussion Return to School Plan for Return to Learning​ and the stages of 3 to 6 of the ​Concussion Return to School Plan for Return to Physical Activity​. Name: ___________________________________________________________ Date:____________________________________________________________ Return to Learning (RTL) Stage 3a ●The student begins with an initial time at school of 2 hours. ●The individual RTL plan is developed by Collaborative Team following the student conference and assessment of the student’s individual needs determining possible strategies and/or approaches for student learning. ○Activities permitted if tolerated by student: ●Activities from previous stage (consult the ​Concussion Return to School Plan for Return to Learning​ and the ​Concussion Return to School Plan for Return to Physical Activity​.) ●School work for up to 2 hours per day in smaller chunks (completed at school) working up to a 1/2 day of cognitive activity ●Adaptation of learning strategies and/or approaches ○Activities that are not permitted at this stage: ●Tests/exams ●Homework ●Music class ●Assemblies ●Field trips School Responsibility ❏The student has demonstrated they can tolerate up to a half day of cognitive activity ❏The School Concussion Management Form (Return to School Plan) is sent home to parents/guardians School Initial:_________________________________________________ Date:_____________________________________________________ OCDSB 970 (June 2020) Page 1 Home Responsibility ❏The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms ❏The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours ❏The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner ❏The School Concussion Management Form (Return to School Plan) is sent back to school Parent/Guardian Signature:__________________________________________ Date:_________________________________________________________________ Comments:____________________________________________________________ Stage 3b ●The student continues attending school half time with gradual increase in school attendance time, increased school work and a decrease in the adaptation of learning strategies and/or approaches. ○Activities permitted if tolerated by student: ●Activities from previous stage ●School work for 4-5 hours per day, in smaller chunks (for example, 2-4 days of school/week) ●Homework – up to 30 minutes per day ●Decrease adaptation of learning strategies and/or approaches ●Classroom testing with accommodations. ○Activities that are not permitted at this stage: ●Standardized tests/exams School Responsibility ❏The student has demonstrated they can tolerate up to 4-5 hours of the cognitive activities listed ❏The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian School Initial:_________________________________________________ Date:_____________________________________________________ Home Responsibility ❏The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms OCDSB 970 (June 2020) Page 2 ❏The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours ❏The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner ❏The School Concussion Management Form (Return to School Plan) is sent back to school Parent/Guardian Signature:_____________________________________________ Date:_________________________________________________________________ Comments:____________________________________________________________ Stage 4a ●Full day school, minimal adaptation of learning strategies and/or approaches ●Nearly normal workload. ○Activities permitted if tolerated by student: ●Activities from previous stage ●Nearly normal cognitive activities ●Routine school work as tolerated ●Minimal adaptation of learning strategies and/or approaches ○Start to eliminate adaptation of learning strategies and/or approaches ○Increase homework to 60 minutes per day ○Limit routine testing to one test per day with accommodations (for example, supports - such as more time) ○Activities that are not permitted at this stage are standardized tests/exams School Responsibility ❏The student has demonstrated they can tolerate a full day of school and a nearly normal workload with minimal adaptation of learning strategies and/or approaches ❏The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian School Initial:_________________________________________________ Date:_____________________________________________________ Home Responsibility ❏The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms ❏The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours ❏The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner OCDSB 970 (June 2020) Page 3 ❏The School Concussion Management Form (Return to School Plan) is sent back to school Parent/Guardian Signature:__________________________________________ Date:_________________________________________________________________ Comments:____________________________________________________________ Stage 4b ●At school: full day, without adaptation of learning strategies and/or approaches ○Activities permitted if tolerated by Student: ●Normal cognitive activities ●Routine school work ●Full curriculum load (attend all classes, all homework, tests) ●Standardized tests/exams ●Full extracurricular involvement (non-sport/non-physical activity, for example, debating club, drama club, chess club) School Responsibility ❏The student has demonstrated they can tolerate a full day of school without adaptation of learning strategies and/or approaches ❏The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian School Initial:_________________________________________________ Date:_____________________________________________________ Home Responsibility ❏The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms ❏The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours ❏The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner Parent/Guardian Signature:____________________________________________ Date:_________________________________________________________________ Comments:____________________________________________________________ OCDSB 970 (June 2020) Page 4 Return to Physical Activity (RTPA) Stage 3 ●Simple locomotor activities/sport-specific exercise to add movement. ○Activities permitted if tolerated by student: ●Activities from previous stage (20-30 minutes walking/stationary cycling/elliptical/recreational dancing at a moderate pace) ●Simple individual drills (for example, running/throwing drills, skating drills in hockey, shooting drills in basketball) in predictable and controlled environments with no risk of re-injury ●Restricted recess activities (for example, walking) ○Activities that are not permitted at this stage: ●Full participation in physical education or Daily Physical Activity ●Participation in intramurals ●Full participation in inter-school practices ●Inter-school competitions ●Resistance or weight training ●Body contact or head impact activities (for example, heading a soccer ball) ●Jarring motions (for example, high speed stops, hitting a baseball with a bat) School Responsibility ❏The student has demonstrated they can tolerate simple individual drills/sport-specific drills as listed in permitted activities ❏The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian School Initial:_________________________________________________ Date:_____________________________________________________ Home Responsibility ❏The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms ❏The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours ❏The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner ❏The School Concussion Management Form (Return to School Plan) is sent back to school Parent/Guardian Signature:___________________________________________________ OCDSB 970 (June 2020) Page 5 Date:_________________________________________________________________ Comments:____________________________________________________________ Stage 4 ●Progressively increase physical activity. Non-contact training drills to add coordination and increased thinking. ○Activities permitted if tolerated by student: ●Activities from previous stage ●More complex training drills (for example, passing drills in soccer and hockey) ●Physical activity with no body contact (for example, dance, badminton) ●Participation in practices for non-contact interschool sports (no contact) ●Progressive resistance training may be started ●Recess – physical activity running/games with no body contact ●Daily Physical Activity ○Activities that are not permitted at this stage: ●Full participation in physical education ●Participation in intramurals ●Body contact or head impact activities (for example, heading a soccer ball) ●Participation in inter-school contact sport practices, or inter-school games/competitions (non-contact and contact) School Responsibility ❏The student has completed the activities in Stage 4 as applicable ❏The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian ❏A Concussion Medical Clearance Form is sent home to parent/guardian School Initial:_________________________________________________ Date:_____________________________________________________ Home Responsibility ❏The student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms ❏The student has exhibited or reported a return of symptoms, or new symptoms, and must return to the previous stage for a minimum of 24 hours ❏The student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner ❏The School Concussion Management Form (Return to School Plan) is sent back to school Parent/Guardian Signature:______________________________________________ Date:_________________________________________________________________ OCDSB 970 (June 2020) Page 6 Comments:____________________________________________________________ ●Before progressing to Stage 5, the student must: ■have completed Stage 4a and 4b of RTL (full day at school without adaptation of learning strategies and/or approaches); ■have completed Stage 4 of RTPA and be symptom-free; and ■obtain a signed medical clearance from a medical doctor or nurse practitioner. ●Please Note: Premature return to contact sports (full practice and game play) may cause a significant setback in recovery Stage 5 ●Following medical clearance, full participation in all non-contact physical activities (that is, non-intentional body contact) and full contact training/practice in contact sports ○Activities permitted if tolerated by student: ●Physical Education ●Intramural programs ●Full contact training/practice in contact interschool sports ○Activities that are not permitted at this stage are any competition (for example, games, meets, events) that involves body contact School Responsibility ❏The student has successfully completed the applicable physical activities in Stage 5 ❏The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian School Initial:_________________________________________________ Date:_____________________________________________________ Home Responsibility ❏The student has not exhibited or reported a return of symptoms or new symptoms ❏The student has exhibited or reported a return of symptoms or new symptoms and must return to medical doctor or nurse practitioner for a Medical Clearance reassessment ❏The School Concussion Management Form (Return to School Plan) is sent back to school Parent/Guardian Signature:___________________________________________ Date:_________________________________________________________________ OCDSB 970 (June 2020) Page 7 Comments:____________________________________________________________ Stage 6 ●Unrestricted return to contact sports. Full participation in contact sports games/competitions School Responsibility ❏The student has successfully completed full participation in contact sports ❏The School Concussion Management Form (Return to School Plan) is sent home to parent/guardian School Initial:_________________________________________________ Date:_____________________________________________________ Home Responsibility ❏The student has not exhibited or reported a return of symptoms or new symptoms ❏The student has exhibited or reported a return of symptoms or new symptoms and must return to medical doctor or nurse practitioner for a Medical Clearance reassessment ❏The School Concussion Management Form (Return to School Plan) is sent back to school for documentation purposes Parent/Guardian Signature:___________________________________________________ Date:_________________________________________________________________ Comments:____________________________________________________________ The personal information on this form is collected under the authority of the Education Act (R.S.O. 1990 c.E2), 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 the management of student learning and wellbeing, and for 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 health and safety, or discipline related to law enforcement matters. 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. CONFIDENTIAL WHEN COMPLETED. OCDSB 970 (June 2020) Page 8