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<br />Appendix D <br />PR.561.SCO <br />OCDSB 908: Documentation of Medical Examination <br /> <br /> <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 /> <br /> <br />_________________________ (student name) sustained a suspected concussion, on ___________________ <br />(date). As a result, the OCDSB recommends that the student be seen by a medical doctor or nurse <br />practitioner. <br />Prior to returning to school and/or physical activity, the parent/guardian must inform the school principal of the <br />results of the medical examination by completing the following: <br /> <br />Results of Medical Examination <br /> <br />no concussion <br /> My child has been examined and has been diagnosed and therefore may resume <br /> <br />full participation in learning and physical activity with no restrictions. <br /> <br />a concussionhas been diagnosed <br /> My child has been examined and and therefore must begin a <br /> <br />medically supervised, individualized and gradual Return to Learn/Return to Physical Activity Plan. <br /> <br />has been examined <br /> My child but I have chosen not to obtain medical documentation and give <br /> <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 /> <br />Parent/Guardian signature: ________________________________ <br /> <br />Date: _____________________ <br /> <br />Comments: <br />________________________________________________________________________________________ <br /> <br />________________________________________________________________________________________ <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 /> <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 /> <br />years of age.Any questions with respect to this information should be directed to the school principal. <br /> <br />OCDSB 908 <br />