North Carolina's Gfeller-Waller Concussion Awareness Act sets requirements for clearing student-athletes after a concussion. NCHSAA's Form C records a licensed health care provider's recommendations from that day's evaluation: whether the student stays out of school or returns with accommodations, and whether and how the student may start the Return to Play protocol.
A licensed MD, DO, athletic trainer, PA, NP, neuropsychologist or physical therapist completes the form, initials the recommendations selected and signs. A second signature line names anyone to whom aspects of care are delegated.
Download the current version from the source each time; forms change without notice.
Licensed Health Care Provider Concussion Evaluation Recommendation
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A licensed health care provider: physician (MD or DO), athletic trainer, physician assistant, nurse practitioner, neuropsychologist or physical therapist. NCHSAA strongly encourages expertise and training in concussion management, and strongly recommends physician input before full clearance.
Form C says emergency room and urgent care physicians should not make clearance decisions at the time of the first visit, because concussions need monitoring for recurring symptoms with cognitive or physical stress. They can still record recommendations such as not cleared and return for evaluation.
Not cleared for sports or PE, light activity with no risk of head trauma, return to the examining provider before clearance, or start the Return to Play protocol under monitoring by a licensed provider or a first responder, with review points before stage 4 and after stage 5.