CONCUSSION RETURN TO PLAY FORM

The USA Hockey Concussion Management Protocol and most state statutes require that an athlete be removed

from any training, practice or game if they exhibit any signs, symptoms or behaviors consistent with a concussion

or are suspected of sustaining a concussion. The player should not return to physical activity until he or she has

been evaluated by a qualified medical provider who has provided written clearance to return to sports.

This form is to be used after an athlete has been removed from athletic activity due to a suspected

concussion and must be signed by their medical provider in order to return without restriction to training,

practice or competition.