HomeMy WebLinkAboutOCDSB 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
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