Return-to-play protocol form (PDF)
A printable one-page form that walks through the 6-step graduated return, with heart-rate target zones and a provider sign-off line. Bring it to your appointment.
Download the form (PDF)Free concussion return-to-play form (printable PDF)
A free, ready-to-use printable return-to-play clearance form from a board-certified sports neurologist: the 6-step graduated return with heart-rate zones, the symptom threshold, and a provider sign-off line for athletes, parents, coaches, and clinicians.
Quick answer
Yes, this page's one-page return-to-play protocol form is free to download and print. It lays out all six graduated steps with heart-rate target zones and a provider sign-off line, so a clinician can complete and sign it for an athlete.
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This resource is educational and does not replace evaluation and written clearance by a qualified healthcare provider. Most states legally require written clearance before an athlete returns to contact play. See return-to-play rules by state.
The 6-step graduated return-to-play protocol
After a concussion, athletes return to sport through a supervised, stepwise progression rather than all at once. Each step lasts a minimum of 24 hours. Mild, brief symptoms that stay within a tolerable threshold, an increase of no more than 2 points on a 0–10 scale lasting under an hour, are acceptable as the athlete progresses. A larger spike (a rise of 3 or more points), or symptoms that do not settle, means easing back to the previous well-tolerated step before trying again. Steps 4–6 should begin only after symptoms, cognitive function, and any clinical findings have resolved.
Symptom-limited activity
Normal daily activities (school, work, light walking) that don't provoke symptoms. No sport yet.
Light-to-moderate aerobic exercise
Walking or stationary cycling, first at a slow pace up to about 55% of maximum heart rate (Step 2A), then at a medium pace up to about 70% of maximum heart rate (Step 2B). No resistance training at first.
Sport-specific exercise
Running or skating drills with no head-impact activity.
Non-contact training drills
Harder, non-contact drills; may add progressive resistance training and greater thinking load.
Full-contact practice
Only after written medical clearance; return to normal training including contact.
Return to sport
Full game play and competition.
This framework follows the internationally used graduated return-to-sport strategy (CDC HEADS UP / 2022 Amsterdam Consensus). The downloadable form above lays it out as a printable checklist with a provider sign-off line.
Target heart-rate zones for Step 2
Predicted maximum heart rate is estimated as 220 − age. Step 2A is light effort (up to ~55% of max); Step 2B is moderate effort (up to ~70% of max).
| Age | Predicted max HR | Step 2A: Light (~55%) | Step 2B: Moderate (~70%) |
|---|---|---|---|
| 14 | 206 bpm | ~113 bpm | ~144 bpm |
| 16 | 204 bpm | ~112 bpm | ~143 bpm |
| 18 | 202 bpm | ~111 bpm | ~141 bpm |
| 20 | 200 bpm | ~110 bpm | ~140 bpm |
| 22 | 198 bpm | ~109 bpm | ~139 bpm |
Return-to-play by sport
The graduated steps are the same, but what each step looks like differs by sport: heading in soccer, contact in football, fit-to-drive testing in motorsport. See return-to-play by sport for sport-specific guidance, including football, soccer, basketball, cricket, and motorsport.
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Frequently Asked Questions
Quick answers about the return-to-play form and the 6-step protocol.
What are the steps of returning to play after a concussion?
The standard graduated return-to-play protocol has six steps: symptom-limited daily activity, light-to-moderate aerobic exercise (Step 2A up to ~55% of max heart rate, then Step 2B up to ~70%), sport-specific exercise, non-contact training drills, full-contact practice after written medical clearance, and return to competition. Each step lasts at least 24 hours; mild, tolerable symptoms (a rise of no more than 2 points on a 0–10 scale) are acceptable, while a larger spike means easing back a step.
How many days does return to play take after a concussion?
Because each of the six steps takes a minimum of 24 hours, the fastest possible graduated return is about one week once an athlete is stable at rest. Many athletes, especially youth, take longer, and that's normal. A significant rise in symptoms at any step means dropping back to the previous well-tolerated step.
What is the RTP protocol for concussions?
RTP (return-to-play) is the stepwise, supervised progression from rest back to full sport. The athlete advances one step at a time, tolerating only mild symptoms that stay within a threshold, and must receive written clearance from a qualified provider before full-contact participation, as required by most state laws.
What is the 20-20-20 rule for concussions?
The 20-20-20 rule is a screen-break guideline some clinicians suggest during recovery. Every 20 minutes of screen time, look at something about 20 feet away for 20 seconds. It can help manage screen-triggered symptoms but is not a formal part of the return-to-play protocol.
Is there a free printable concussion return-to-play form?
Yes. The one-page return-to-play protocol form on this page is free to download and print. It lays out all six graduated steps with heart-rate target zones and a provider sign-off line, so a clinician can complete and sign it for an athlete.
Can schools and teams use this as a concussion policy template?
The form clears one athlete; a school or team also needs a program-wide policy. Our guide to what a school or team concussion policy should include walks through every section a defensible policy needs, building this same 6-step return-to-play protocol into a complete program-level policy.
What should a return-to-play clearance form include?
A good clearance form records the athlete's name and date of birth, the injury date, the graduated return-to-play steps completed, confirmation the athlete is symptom-free, and the provider's name, credentials, signature, and date, with a clear statement clearing the athlete for unrestricted play.