Iowa Code 280.13C keeps a student removed for a suspected concussion out of play until a licensed health care provider clears them. This form, shared by the IHSAA and IGHSAU, records the provider's decisions in three boxes: not cleared, cleared to start steps 1 to 3 of the return-to-play protocol, and, after re-evaluation, cleared for steps 4 to 6.
The licensed health care provider enters name, phone, and license number and board, completes box A, B or C, and signs or initials it; box B names the provider overseeing steps 1 to 3. A parent or guardian signs the permission and release.
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Concussion Evaluation and Return to Play Form for Licensed Healthcare Providers
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Box A: not cleared for any sports activity, including gym or weightlifting, until a follow-up evaluation. Box B: may start steps 1, 2A, 2B and 3 on a set date under monitoring. Box C: after re-evaluation, the student finished steps 1 to 3, is asymptomatic and may start steps 4 to 6.
At least 7 days. After 24 to 48 hours of relative rest, each step is separated by at least 24 hours, and some students need a delayed protocol. Final return-to-play clearance comes once the student is fully back to the classroom and has completed the protocol.
A licensed health care provider, identified on the form by name, license number and licensing board. The form refers providers to Iowa Code 280.13C and the related chapter 54 rules for which licensed professionals qualify to evaluate and clear a student.