Concussion Forms and Resources

Physician Letter To School

How to use this form:

  • This is the initial medical form required to indicate that your student has been evaluated for concussion and will indicate a definitive diagnosis or will conclude that your student does NOT have a concussion diagnosis and has no restrictions.
  • If your student has a definitive concussion diagnosis, this form must be submitted again once your student has fully recovered from concussion and the physician documents that your student may return to full cognitive activity and (graduated) physical activity.

Concussion Symptom Checklist

How to use this form:

  • The CIF Graded Concussion Symptom Checklist Form is recommended for parents/guardians and student-athletes to use when communicating signs and symptoms of a concussion to their physician. This form should be completed as a baseline at the beginning of the season and also used after a suspected concussion as a checklist to record daily symptoms.

Physician Recommended School Accommodations Following A Concussion

How to use this form:

  • The CIF Physician (MD/DO) Recommended School Accommodations Following Concussion Form is recommended for use by all parties involved with returning a student experiencing concussion to the classroom. This is a dynamic tool that is best use as a means of communicating what a student's current cognitive status is and what type of academic accommodations will be most supportive.

Concussion Return To Learn (RTL) Protocol

How to use this form:

  • The CIF Concussion Return to Learn (RTL) Protocol Form is recommended for use by all parties involved with returning a student-athlete to the classroom. It provides a dynamic timeline for supporting concussion recovery with suggested accommodations.

Concussion Return To Play (RTP) Protocol

How to use this form:

  • Graduated Return To Play Protocol will be facilitated and monitored by Acalanes Certified Athletic Trainer, Chris Clark.
  • Medical science and concussion care experts have found that a concussed athlete must take a gradual and progressive, stage by stage, step by step return to practice under medical supervision to minimize risks and allow the brain to properly recover.
  • A.B. 2127 and CIF Bylaws mandated a MINIMUM timeline, but medical experts recognize that many adolescent concussion patients may take much longer to recover. Always be cautious as returning to practice and play too quickly may have catastrophic consequences.