Massachusetts regulations (105 CMR 201) require medical clearance before a student removed from an extracurricular athletic activity for a head injury or suspected concussion returns. DPH's form records it in two stages: clearance to begin a gradual return-to-play protocol, and certification that the student has completed it and is cleared for full activity without restriction.
A physician, licensed athletic trainer, physician assistant, nurse practitioner or neuropsychologist completes and signs it, attesting to DPH-approved or equivalent training; non-physicians must work in consultation with a licensed physician, who is named on the form.
Download the current version from the source each time; forms change without notice.
Post Sports-Related Head Injury Medical Clearance and Authorization Form
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A physician, licensed athletic trainer, physician assistant, nurse practitioner or neuropsychologist with DPH-approved or equivalent training in post-traumatic head injury. Athletic trainers, NPs, PAs and neuropsychologists must work in consultation with a licensed physician, whose name goes on the form.
Only once the student is back in the classroom full time without concussion-related academic accommodations. The form asks the provider to discuss the student's classroom experience and any symptoms during schoolwork before checking the box to begin the gradual protocol.
Yes. The Department of Public Health posts the Post Sports-Related Head Injury Medical Clearance and Authorization Form in English, Spanish and Portuguese, each as a PDF and a Word file, on its list of required forms for schools with extracurricular sports.