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OCDSB 908: Documentation of Medical <br />Examination <br />This form to be provided to all students with a suspected concussion, as described in <br />OCDSB 903: Concussion Awareness Tool. It is not required after every incident. <br />_________________________ (student name) sustained a suspected concussion <br />on ___________________ (date). As a result, the OCDSB recommends that the student be seen by a medical <br />doctor or nurse practitioner. <br />Prior to returning to school and/or physical activity, the parent/guardian must inform the school <br />principal of the results of the medical examination by completing the following: <br />Results of Medical Examination <br />My child has been examined and no concussion has been diagnosed and therefore may resume <br />full participation in learning and physical activity with no restrictions. <br />My child has been examined and a concussion has been diagnosed and therefore must begin a <br />medically supervised, individualized and gradual Return to Learn/Return to Physical Activity Plan. <br />My child has been examined but I have chosen not to obtain medical authorization and give <br />permission for my child to assume full participation in the learning and physical activity with no <br />restrictions during the core instructional day. I understand that this does not include extra- <br />curricular activities where there may be requirement for medical authorization, dependent on the <br />nature of the extra-curricular activity. <br />Parent/Guardian signature: ________________________________ <br />Date: _____________________ <br />Comments: <br />________________________________________________________________________________________ <br />________________________________________________________________________________________ <br />___________________________________________________________________________________________________________ <br />Freedom of Information Notice <br />The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act and <br />its regulations. This information is protected under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and <br />will be utilized only for the purpose of managing student learning and well being. Access to this information will be limited to those who <br />have an administrative need, to the student to whom the information relates and the parent(s)/guardian (s) of a student who is under 18 <br />years of age. Any questions with respect to this information should be directed to the school principal. <br />I understand that the Ottawa-Carleton District School Board recommends by child receive medical <br />attention.