Division of Orthopaedic Surgery and Sports Medicine
225 E. Chicago Avenue, Box 69, Chicago, Illinois 60611-2605
312.227.6190 Fax: 312.227.9404
luriechildrens.org
Date:
Name:
DOB:
This letter is to certify that__________________ was seen today by______________, MD at
the Institute for Sports Medicine at Ann & Robert H. Lurie Children's Hospital of Chicago.
He/she is under my care for concussion. Please excuse the patient from school today due to a
medical appointment. It is suggested that the following recommendations be implemented to
avoid increasing concussion symptoms and delaying recovery.
Please be sure that all members of the student's learning team are aware of the following
accommodations.
Please allow the following academic recommendations from ____to ____.
Attendance
____No School for ____days
____No School until symptom free or significant decrease in symptoms
____Once symptoms improve, please allow student to begin attending partial school days as tolerated.
____Part-time attendance as tolerated
____Please allow student to attend every other class period as tolerated, resting in the nurse's office between
classes.
____Student may add classes back and decrease breaks as tolerated, progressing to a full school day as symptoms
allow.
____Full school days as tolerated
____Homebound tutoring as tolerated
Breaks
____Please determine a non-verbal cue for the student to notify the teacher if symptoms have increased and needs
to take a break. For example, the student will lay a notecard at the corner of their desk.
____Please allow the student to put his head down on the desk for a brief rest as needed. If this does not help
decrease symptoms, please allow him to go to the nurse's office.
____Allow student to go to the nurse's office if symptoms increase
____Allow student to go home if symptoms do not subside or improve to a manageable level
Visual Stimulus
____Allow student to wear sunglasses in school
____Pre-printed notes for class material or note taker
____Limit smart boards, projectors, computers, TV screens, or other bright screen
____Enlarged font when possible
____Please allow for a short break (10-15 minutes) during prolonged screen time and/or reading and writing.
Audible Stimulus
____Allow student to leave class 5 minutes early to avoid noisy hallway
____Lunch in a quiet place
____Audible learning (discussions, reading out loud, if possible text to speech programs or Kindle, and/or audio
books)
____Please allow for a short break (10-15 minutes) as needed when in a noisy environment, i.e. band and/or music
class, school assembly or pep rally.
____Please allow student to refrain from band, orchestra, choir, music, and/or theater class, practices, and
rehearsals.
____Please allow student to resume *** as tolerated.
Workload/Multi-Tasking
____Reduce overall amount of make-up work, class work, and homework to essential materials only (enough to
demonstrate concept mastery).
____No homework
____No in-class reading or writing
____Limit homework to *** minutes a night
____Resume homework as tolerated
____Please delay large assignments until student is further recovered.
____No due dates for homework assignments
____Extra time to complete homework and reading assignments
____Limit in-class reading and writing seatwork to 10 minutes/class period as tolerated
Testing
____No testing
____No scantron testing. Please allow student to write directly on test itself.
____Extra time to complete tests
____No more than one test a day
____Divide longer tests into multiple sections to allow for up to a 30-minute break between sections
____Oral testing
____Open book testing
____Resume testing as tolerated
____Please *** standardized testing
Physical Exertion
____No physical exertion/athletics/physical education class
____No recess
____Begin return-to-play protocol prior to returning to PE class or athletics
____Non-contact activities/sports in Physical Education class only
____Please allow student to use their PE class period as a study hall or rest period in a quiet place.
____Please allow student to rest if symptoms increase with activity.
____The student should not participate in any activities or environments that place him at risk to further injury, i.e. the
sideline.
Additional Recommendations
____No driving
____Limit television, text messaging, video games and computer work
____Please allow preferential seating to minimize distractions and extraneous visual and audible stimuli.
____Please provide a tutor as needed for ***.
Current Symptom List:
____Headache
____Drowsiness
____Balance problems
____Sleeping less than usual
____Feeling slowed down
____Difficulty remembering
____Irritability
____Nausea
____Numbness or tingling
____Sleeping more than usual
____Sensitivity to light
____Feeling as if "in a fog"
____Trouble falling asleep
____Sadness
____Vomiting
____Dizziness
____Fatigue and Visual problems
____Sensitivity to noise
____Difficulty concentrating
____More emotional than usual
____Nervousness
The patient has been scheduled for a follow-up medical appointment and revision of
recommendations on________.
The academic accommodations may help in reducing the cognitive (thinking) load,
thereby minimizing post-concussion symptoms and allowing the student to better
participate in the academic process during the injury period. Needed accommodations
may vary by course. The student and parent are encouraged to discuss and establish
accommodations with the school on a class-by-class basis. The student and parent may
wish to formalize accommodations through an IEP or 504 Plan if symptoms persist
following treatment and less formalized accommodations.
Testing: Students with a concussion have increased memory and attention problems. They will
not be able to learn as effectively or as quickly as before. High demanding activities like testing
can significantly increase symptoms (e.g., headache, fatigue, fogginess, dizziness) which in turn
can make testing more difficult.
Note Taking: Note taking may be difficult due to impaired multi-tasking abilities and increased
symptoms.
Work Load Reduction: It takes a concussed student much longer to complete assignments
due to increased memory problems and decreased speed of learning. Recovery can be delayed
when a student "pushes through” symptoms. Therefore, it is recommended that “thinking” or
cognitive load be reduced, just as physical exertion is reduced. Examples of how to shorten
work might be to reduce the length of essays, have the student do every other problem in a
homework assignment, or highlight key concept areas for testing while eliminating testing on
less important topics. Doing school work in 15 minute intervals, followed by a rest break, is often
needed.
Breaks: Take breaks as needed to control symptom levels. For example, if the headache
worsens during class, the student should put his or her head on the desk to rest. For worse
symptoms, he/she may need to go to the nurse’s office to rest prior to returning to class.
Extra Time: Students may experience severe symptoms some days or nights and not others.
With increased symptoms, students are advised to rest, and therefore may need to turn
assignments in late on occasion.
School Environment: The school setting has a variety of constant visual and audible stimuli.
Loud and noisy classrooms, hallways, auditoriums and cafeterias can provoke symptoms in
concussed students. Bright halogen lights, smart boards and projectors are visual stimulus that
often exacerbates symptoms. Modifications of this stimulus may be needed during the student’s
school day. Allowing students to leave class five minutes early to avoid loud hallways or eat in a
quiet place during lunch, allowing pre-printed notes or use of sunglasses are options.
Physical Exertion: At no point shall a student return to contact or collision activities while
currently experiencing symptoms. Return-to-play protocols must be completed with a certified
athletic trainer or other medical provider experienced with return-to-play protocols. Non-contact
aerobic activities will be prescribed by the medical provider as tolerated.
For more information, please visit www.luriechildrens.org/rtl for our free online training unit that
provides guidance for teachers, school nurses, counselors and administrators on how to
integrate children and teens back into school following concussion.
____________ MD
Division of Orthopaedic Surgery and Sports Medicine
Ann & Robert H. Lurie Children's Hospital of Chicago