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Manatee Baseball Inc.
Concussion Instructions and Return to Play Clearance Form

Your child/ward may have sustained a concussion, and by policy has been removed from play until he/she has been medically cleared to return to play by a quali?ed health care professional.

It is not within our purview to dictate how or by whom your child/ward should be managed medically. The following have been adapted from guidelines published by the National Athletic Trainer's Association and serve as general guidelines only for immediate management during the ?rst 24 hours:

It is OK to:
Use acetaminophen (Tylenol) for headaches Eat a carbohydrate-rich diet Use ice pack on head and neck as needed for comfort
Go to sleep Rest (no strenuous activity or sports)
There is NO need to:
Check eyes with ?ashlight Test re?exes Wake up frequently (unless otherwise instructed)
Stay in bed
Drink alcohol Drive a car or operate machinery Engage in physical activity (eg, exercise, weight lifting, physical education, sport participation) that makes symptoms worse
Engage in mental activity (eg, school, job, homework, computer games) that makes symptoms worse
Do Monitor for Significant Changes:
Conditions may change signi?cantly within the next 24 hours. Immediately obtain emergency care for any of the following signs or symptoms:

Persistent or projectile vomiting Slurred speech or inability to speak
Unequal pupil size
Can't recognize people or places - increasing confusion
Difficulty in being aroused Weakness or numbness in the arms or legs

Clear or bloody drainage from the ear or nose Unusual behavior change - increasing irritability
Continuing or worsening headache
Loss of consciousness Seizures Improvement

The best indication that an athlete who has suffered a signi?cant head injury is progressing satisfactorily, is that he/she is alert and behaving normally.

Contact your health care provider

Before returning to physical activities, contact your health care provider for evaluation. Use the attached form to help your health care provider determine if your child sustained a concussion and when your child/ward is fully recovered and able to resume normal activities, including sports.

Talk to your health care provider about the following:

- Management of symptoms
- Appropriate levels of school activity or the need for reducing academic coursework for a temporary period of time
-Appropriate levels of physical activity
Return clearance form prior to returning your child to play

Concussion Return to Play Clearance Form

To: Health Care Provider

This form has been developed in order to provide a uniform method for health care professionals to provide a written release for student/athletes to retum to play after having suffered a concussion or having demonstrated signs, symptoms, or behaviors consistent with a concussion and having been removed from competition or practice as a result.

As of May 2011, Utah State Law requires that a child suspected of having sustained a concussion be removed from sporting events and prohibited from returning to play until that child has been evaluated by an appropriate health care provider.

The law requires the following of the health care provider:
- Provide the amateur sports organization with a written statement, stating that within 3 years before the day on which the written statement is made that they have successfully completed a continuing education course in the evaluation and management of concussion.
~ Provide the amateur sports organization written clearance that the child is cleared to resume participation in the sporting event of the amateur sports organization
While this form does not presume to dictate to professionals how to practice medicine, the guidelines for return to play from a concussion do represent consensus expert opinion from national and world leaders in sport concussion management." The components of this form are intended to address concems of coaches, parents, student/athletes, administrators, and healthcare professionals regarding written clearance from a health care professional for a concussed student/athlete to return to play.
In order to maintain compliance with the law, our organization requests that the healthcare provider utilize this form in granting medical clearance to return to sporting events.
If the athlete is not yet appropriate to return to competition or advance through the return to play protocol, do not fill out the clearance form. Rather, provide a separate written statement of this medical recommendation.


- Recovery from concussion and progressi on through the Return-to-Play stages is individualized and deterni ?ed On a case by case basis. Many factors in?uence the rate of progression and include previous concussion history, duration and types of symptoms, age and sport/activity in which the student/athlete participates.

- Student/athletes with a history of prior concussion, extended duration of symptoms, or participation in collision or contact sports may progress more slowly.

- It is expected that a student-athlete hassuccessfully and completely reintegrated back to school prior to returning to competition

' The following table is adapted from the 5'" Intemational Conference on Concussion in Sport' and provides the framework for the return to play protocol.
' It is expected that student/athletes will start in stage l and remain in stage 1 until symptom free. Under the guidance of a quali?ed health care provider, symptom limited physical exertion may be started prior to reaching symptom free status.
~ The patient may, under the direction of a health care professional, progress to the next stage only when the assessment battery has normalized. The assessment battery may include any or all of the following:
a. Symptom assessment
b. Cognitive assessment with computerized or other appropriate neuropsychological assessment
c. Balance assessment along with general neurologic examination.

-l--- UHSAA Concussion lnstructions and Return to Play Clearance Form
' It is anticipated that at least 24 hours will be required, at a minimum, of being asymptomatic with each stage before progressing to the next stage.
- Utilizing this framework, in a best case scenario, a patient sustaining a concussion and being asymptomatic by the next day will start in Rehabilitation Stage l at post injury day l and progress through to stage 6,
'Return to Play' by post injury day 6.
~ There may be circumstances, based on an individual's concussion severity, where the return to play protocol may take longer. Under all circumstances the progression through this protocol shall be overseen by the managing health care professional.
- Each athlete with a concussion shall be personally evaluated by an appropriate health care professional at least one time during this process.
~ When the athlete has successfully passed through stage 5 (Full Contact Practice) and has previously been evaluated by an appropriate health care professional or recognized concussion management program, a clearance may be obtained from the individual designated on this form if authorized by the managing health care professional.
- A completed Concussion Return to Play Clearance Form indicating the student is medically released to return to full competition shall be provided to school of?cials prior to a student who has been removed from a contest or practice for a suspected concussion, being allowed to retum to play.

Stage Functional Exercise or Activity Objective
1. Symptom-limited activity after 24- _ _ _ _ _ _ Gradual reintroduction of 48 hours of relative physical and Activities of Daily Living. (ADLs) that do not provoke symptoms.' work/schooi activities cognitive res' When Indicated, cognitive rest followed by gradual reintroduction
Aerobic Physical Acmmy Non~impact aerobic activity (e.g. swimming, stationary biking) at lncrefile heart rate' maintain 0 . . . condition, assess tolerance of
A estimated maximum heart rate (slow to medium pace) for activity
Date Tested: up to 30 minutes as symptoms allow. Date Geared: Initial: 3' Moderate aerobic p.hy.sica| c?vity N0n-contact sport specific drills at reduced speed; Aerobic Begin asm?la?on mm mam . and Non-contact training drills at . . . _ _ dynamics, introduce more motion halfs eed activity at 70-85% estimated maximum heart rate; light and non im act _arrin p resistance training (e.g. weights at <50% previous max ability) P J g
Date Tested: Date Cleared: Initial: 4' N"'c'"act "ainmg drills at fun Regular Non-contact training drills; aerobic activity at maximum Ef\$lll'e !|9i'a|'"3e f all |'B\-||3|' speed capacity including sprints; regular weight lifting routine. As part 3tiVitie5 5h|'\ Of Pl'lY5iC3l "'53t of this stage, return to regular school activities has also been and aiidemili Wi'k- Date Tegfedj 3mP|l5hed- Date Clea red: Initial: 5_ Fuii cnntad Practice Assess functional skills by coaching staff, ensure tolerance of contact activities
Date Te?edi Date Cleared: Initial:
6. Return to Play Regulargame competition