Get Return To Play Concussion Clearance Form - Healthy Arkansas

Completing the Return To Play Concussion Clearance Form is essential for ensuring the safety of youth athletes after a concussion. This guide provides a clear, step-by-step approach to filling out the form online, catering to all users, regardless of their previous legal experience.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by entering the youth athlete’s name in the designated field at the top of the form. This identifies the individual for whom the clearance is being requested.
3. Next, fill in the date of completion, followed by the athlete's date of birth and age, which helps to ensure that all personal details are accurate.
4. Indicate the sport the athlete participates in and the name of their school or team. This information is crucial for tracking the athlete's participation.
5. Identify the reporter of the injury (e.g., patient, parent, caregiver, etc.) and provide their relevant details in the corresponding field.
6. Document the injury characteristics, including the date and time of the injury, and describe the injury itself. Mark any specific injury locations that apply.
7. Answer the questions regarding memory loss, loss of consciousness, and seizures, ensuring that the information provided is truthful and complete.
8. Complete the symptom checklist by marking 'Yes' or 'No' for each symptom experienced since the injury. This section includes physical, cognitive, emotional, and sleep-related symptoms.
9. Indicate whether symptoms worsen with physical or cognitive activity, as this information is critical for assessing the athlete's readiness to return.
10. Review the emergency department referral triggers carefully to ensure that immediate medical attention is sought if necessary.
11. In the medical provider section, the licensed health care provider will make return-to-school/play recommendations based on the athlete's condition, so they should complete this section accurately.
12. Finally, the licensed health care provider must sign the form, indicating their professional endorsement and providing their contact information for follow-up purposes.
13. Once the form is completely filled out, you can save changes, download, print, or share the form as needed.

Complete your forms online today to ensure a safe return to play for youth athletes.