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OCDSB 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