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Athletic Trainer’s Office
Date: _____________________________________________________
Coach: ___________________________________________________
Athlete’s Name: _________________________________________
Injury: ___________________________________________________
Status: Out Limited Go-as-can Full-go
Comments: ______________________________________________
__________________________________________________________
_________________________
AT Signature
(Information below is on reverse side)
Participation Status Guidelines
Please do not allow an injured player back to participation without a note from an athletic trainer.
“Out” means no participation until further notice.
“Limited” means the athlete may participate with some restrictions (ie: no hard running, no contact activities, etc).
“Go-as-can” means the athlete may participate as tolerated. An athlete with this status is often making the transition to full return to sports after an injury and needs a gradual progression left to the discretion of the athlete and coach.
“Full-go” means unrestricted participation.
This model form is published by the National Athletic Trainers’ Association. It is a sample only and was not developed to address specific needs of any particular organization or the specific facts any organization may face. The form should not be used or relied upon without the advice of retained legal counsel. The National Athletic Trainers’ Association disclaims any and all responsibility or liability that may be asserted or claimed arising from reliance upon the use of this form by any person.
-----------------------
Your athlete received the following treatment today:
___ Bandage, Wound Care
___ Cardiovascular Exercise
___ Electrical Stimulation
___ Functional Return to Sports Test
___ Ice, Cold Therapy, Compression
___ ImPACT Concussion Test
___ Injury Evaluation
___ Moist Heat Pack
___ Protective Padding
___ Rehabilitation Exercises
___ Tape
___ Ultrasound
___ Whirlpool
___ Other
Coach’s Injury Report
please see participation status guidelines on reverse side
Time Athlete Left AT Office:
_________________________
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