Alaska ASAA Concussion Return to Play Provider Release

Alaska law (AS 14.30.142) keeps a student removed from practice or a game for a suspected concussion out until a qualified, trained provider evaluates and clears them. ASAA's three-page release records that decision: not yet ready, cleared to begin the six-step return-to-play protocol, or symptom free and finished with it. A separate section covers students the provider finds did not have a concussion.

Who completes it

A licensed health care provider who meets ASAA's definition of currently trained in concussion completes the clearance section and signs with an Alaska license number. The student and a parent sign an acknowledgment of risk, and each completed protocol step is initialed on the table.

Submitting and payment

How to submit it
The signed release goes to the student's school, which uses it to let the athlete begin or finish ASAA's return-to-play protocol.
Who pays
ASAA sets no fee for the release and does not say who pays for the evaluation.

Good to know

  • ASAA counts a provider as currently trained after the CDC concussion course for clinicians within two years, 2 hours of sports concussion CE or CME, or sports medicine, neurology or neurosurgery training.
  • Providers who do not meet the training criteria are told to refer the student to one who does. Signing means taking responsibility for daily monitoring and decisions for the athlete.
  • Each step typically takes at least 24 hours. ASAA expects at least a week for the full progression and notes unrestricted return can take up to a month.
  • Clearance to begin the protocol is no longer effective if the student's symptoms return and persist, so a new evaluation is needed.

Get the official form

Download the current version from the source each time; forms change without notice.

Healthcare Provider Release - Concussion Return to Play Protocol

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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Frequently asked questions

Who can sign the ASAA concussion provider release?

Under AS 14.30.142, a licensed athletic trainer or a qualified person currently trained in concussion evaluation can clear the student. That includes a health care provider licensed in Alaska or exempt from licensure, or someone acting under one. The signer attests to ASAA's training definition and adds an Alaska license number.

What if the student did not have a concussion?

The form has a section for the non-concussed athlete. The provider records that no concussion occurred, writes the medical diagnosis that explains the symptoms, and clears the student either for full sports participation or for limited participation with listed restrictions.

How long does ASAA's return-to-play protocol take?

After 24 to 48 hours of relative rest, the athlete moves through light and moderate aerobic exercise, sport-specific drills, non-contact training, full contact practice and game play. Each step typically takes at least 24 hours, so ASAA expects at least one week, and unrestricted return can take up to a month.