Concussion Medical Clearance Letter - Feb. 2023 - Return to Work, School, and Physical Activity Instructions

Sep 16, 2026

Concussion Medical Clearance Letter template for assessing a patient’s readiness to return to work, school, and physical activities after concussion. Defines a staged return-to-activity approach, emphasizes safe and gradual recovery, and instructs patients to revert to the previous stage for 24 hours if symptoms worsen after Stage 2. Includes sections for medical office details, concussion dates, diagnostic timing, required clearance responsibility, and clinician signatures, plus optional restrictions or accommodations with timelines. Completed by an authorized physician or nurse practitioner; other health care forms should not be accepted.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Concussion Medical Clearance Letter

Patient and Medical Office Details

Dates and Diagnosis Information

Clearance Letter Instructions

Return Participation: Without Restriction / With Restrictions

Return Participation: Without Accommodation / With Accommodation

CONCUSSION Medical Clearance Letter Name of patient To be complete by the Medical Office | Name of the Medical Office | | | --- | --- | | [M.D. / N.P. name](M.D. / N.P. name1)[1](M.D. / N.P. name1) | | | Medical License \# | | | Email / Contact \# | | | Date of Clearance Letter | | To be complete by M.D./N.P./Patient | Date of Concussion | | | --- | --- | | Date of Concussion Diagnosis | | | Medical Clearance require by | | To Whom It May Concern: Patients with a concussion should be assessed and managed by a medical professional. The goal of concussion management is to support the patient’s complete recovery from concussion by promoting a safe and gradual return to activity following a staged approach. For more detailed information and resources, please refer to the Concussion Awareness Training Tool (CATT) at [cattonline.com](cattonline.com). As part of the strategy, this patient had previously been instructed to avoid all activities that could potentially place them at risk of another concussion or head injury until a medical clearance letter is provided (due to organizational requirements, dangerous job duties, contact sports, etc. ) . This patient has explained the organizational requirements and the duties/ activities they participate in, and I have personally completed a medical clearance on this patient. Note that the patient’s recovery is individual. After Stage 2, if new or worsening concussion symptoms are experienced the patient has been instructed to return to the previous stage of the strategy for 24 hours. 1. Depending upon physician or nurse practitioner access, the Medical Assessment Letter may be completed by a nurse with access to a licensed physician or nurse practitioner. Forms completed by other health care professionals (e.g., physiotherapists, chiropractors, and other allied healthcare professionals) should not be accepted. It is recommended that this document be provided to the patient without charge. PCO Clearance Letter (Source CATT) Feb. 2023 1 of 2 Name of patient ☐ This patient can return will FULL participation to work, school or physical activities WITHOUT RESTRICTION.☐ This patient can return to work, school, or physical activities WITH THE FOLLOWING RESTRICTION(S). | Restriction(s) Physical & Cognitive | Details | Timeline | | --- | --- | --- | | | | | | | | | | | | | | | | | ☐ ☐ This patient can return will FULL participation to work, school or physical activities WITHOUT ACCOMMODATION. This patient can return to work, school, or physical activities WITH THE FOLLOWING ACCOMMODATION(S). | Accommodation(s) Physical & Cognitive | Details | Timeline | | --- | --- | --- | | | | | | | | | | | | | | | | | Signature: M. D. / N. P. (please circle appropriate designation 1) 1. Depending upon physician or nurse practitioner access, the Medical Assessment Letter may be completed by a nurse with access to a licensed physician or nurse practitioner. Forms completed by other health care professionals (e.g., physiotherapists, chiropractors, and other allied healthcare professionals) should not be accepted. It is recommended that this document be provided to the patient without charge. PCO Clearance Letter (Source CATT) Feb. 2023 2 of 2

FAQs

Who can complete the medical assessment letter for concussion clearance?

Depending on access, completion may be done by a nurse with access to a licensed physician or nurse practitioner. Forms completed by other health care professionals should not be accepted.

What should a patient do if new or worsening concussion symptoms occur after Stage 2?

The patient should return to the previous stage of the strategy for 24 hours.

What information does the letter include regarding return to work, school, or physical activities?

It provides options for full participation without restriction, participation with restrictions (with details and timeline), full participation without accommodation, or participation with specified accommodations (with details and timeline).

Sep 16, 2026

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