HomeMy WebLinkAboutOCDSB 971 Appendix L Medical Concussion Clearance FormAppendix L: OCDSB 971 Medical Concussion Clearance
The Medical Concussion Clearance Form is for students who have completed Stage 4b
of the Concussion Management Plan for Return to School (RTS) and Stage 4 of the
Concussion Management Plan for Return to Physical Activity (RTPA). The student must
be medically cleared by a medical doctor/nurse practitioner prior to moving on to full
participation in non-contact physical activities and full contact practices (RTPA Stage 5).
Student Name:
Date:
I have examined this student and confirm they are medically cleared to participate in the
following activities:
Full participation in Physical Education classes
Full participation in Intramural physical activities (non-contact)
Full participation in non-contact Interschool Sports (practices and competition)
Full-contact training/practice in contact Interschool Sports
Other comments:
Medical Doctor/Nurse Practitioner
In rural or northern regions, the Medical Clearance Form may be completed by a nurse
with pre-arranged access to a medical doctor or nurse practitioner. Forms completed by
other licensed healthcare professionals should not be otherwise accepted.
Name:
Signature:
Date:
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 971 (June 2020)Page 1
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