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Suspected Concussion Return to Play Certification Form

 

Athlete: ___________________________

Sport: ____________________________________

Team: ____________________________________

 

1) Athlete was examined by Healthcare Professional and it was diagnosed that the Athlete did NOT suffer a concussion.  Athlete is cleared to resume full athletic activities.

 

I attest that the Athlete was examined and did not suffer a concussion.  Athlete is cleared to play in all practices and games:

 

Parent/Guardian Name: ___________­________________ Date: ____________

Parent/Guardian Signature: ___________­________________

 

Healthcare Professional Name: ___________­________________ Date: ____________

Healthcare Professional Signature: ___________­________________

 

OR

 

2) Athlete was examined by Healthcare Professional and it was diagnosed that the Athlete DID suffer a concussion. 

 

Athletes who have sustained a concussion MUST complete a graduated Return to Play with a Healthcare Professional once cleared to resume activities based on CDC Guidelines as attached.

 

Date Cleared to Begin Return to Play Protocol: ______________________

Date Competed Return to Play Protocol: ______________________

 

I attest that the Athlete has successfully completed a graduated Return to Play protocol is cleared to play in all practices and games:

 

Parent/Guardian Name: ___________­________________ Date: ____________

Parent/Guardian Signature: ___________­________________

 

Healthcare Professional Name: ___________­________________ Date: ____________

Healthcare Professional Signature: ___________­________________

 

 

Return to Play Progression - Based on CDC Guidelines (http://www.cdc.gov/headsup/providers/return_to_activities.html)

There are five gradual steps to help safely return an athlete to play:

 

Baseline: No Symptoms

As the baseline step of the Return to Play Progression, the athlete needs to have completed physical and cognitive rest and not be experiencing concussion symptoms for a minimum of 24 hours. Keep in mind, the younger the athlete, the more conservative the treatment.

 

Day 1: Light aerobic activity

The Goal: Only to increase an athlete’s heart rate.

The Time: 5 to 10 minutes.

The Activities: Exercise bike, walking, or light jogging.

Absolutely no weight lifting, jumping or hard running.

 

Day 2: Moderate activity

The Goal: Limited body and head movement.

The Time: Reduced from typical routine.

The Activities: Moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting

 

Day 3: Heavy, non-contact activity

The Goal: More intense but non-contact

The Time: Close to typical routine

The Activities: Running, high-intensity stationary biking, the player’s regular weightlifting routine, and non-contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.

 

Day 4: Practice & full contact

The Goal: Reintegrate in full contact practice.

 

Day 5: Competition

The Goal: Return to competition.

 

It is important to monitor symptoms and cognitive function carefully during each increase of exertion. Athletes should only progress to the next level of exertion if they are not experiencing symptoms at the current level. If symptoms return at any step, an athlete should stop these activities as this may be a sign the athlete is pushing too hard. Only after additional rest, when the athlete is once again not experiencing symptoms for a minimum of 24 hours, should he or she start again at the previous step during which symptoms were experienced.

 

The Return to Play Progression process is best conducted through a team approach and by a health professional who knows the athlete’s physical abilities and endurance. By gauging the athlete’s performance on each individual step, a health care professional will be able to determine how far to progress the athlete on a given day. In some cases, the athlete may be able to work through one step in a single day, while in other cases it may take several days to work through an individual step. It may take several weeks to months to work through the entire 5-step progression.