Policy/Program Memorandum 158

Date of Issue: September 25, 2019

Effective: January 31, 2020, until revoked or modified

Subject: School board policies on concussion

Application: Directors of Education
Supervisory Officers and Secretary-Treasurers of School Authorities Principals of Elementary Schools
Principals of Secondary Schools
Principals of Provincial and Demonstration Schools

Reference: This memorandum replaces Policy/Program Memorandum No. 158, March 19, 2014.

Introduction

The Ministry of Education is committed to helping all students^{footnote 1[1]} succeed and lead safe, healthy, and active lives. As part of its commitment to student safety, injury prevention, and well-being, the Ministry of Education supports concussion awareness, prevention, identification, management, tracking, and training in schools^{footnote 2[2]} through legislation, policy, and resources.

The purpose of this updated memorandum is to reflect legislative and policy changes that have occurred since the original memorandum on school board^{footnote 3[3]} policies on concussion was released in 2014. This memorandum addresses concussion safety across all school and school board activities and applies to all publicly funded elementary and secondary schools. It does not apply to licensed child-care providers, including those operating on the premises of publicly funded schools.

On March 7, 2018, the Ontario government enacted Rowan's Law (Concussion Safety), 2018, and amended the Education Act, to protect amateur athletes, including students, by improving concussion safety on the field and at school. The amendments to the Education Act came into force on July 1, 2019, and give the Minister of Education the authority to require school boards to comply with policy and guidelines on concussions, consistent with Rowan's Law.^{footnote 4[4]}

With the authority under the Education Act, the Minister requires all school boards in Ontario to have a policy on concussion safety for students that meets certain minimum requirements, as outlined in this memorandum. All school board policies must, at a minimum, require:

• receipt of confirmation of annual review of approved Concussion Awareness Resources^{footnote 5[5]} by individuals participating in board-sponsored interschool sports
• the establishment of Concussion Codes of Conduct for individuals participating in board-sponsored interschool sports, and the receipt of confirmation of annual review of the relevant Code of Conduct by those individuals
• annual concussion training for relevant school staff
• the establishment of a process for the removal of students with a suspected concussion from physical activity and, for those diagnosed with a concussion, a Return to School Plan, which includes their return to learning and to physical activity
• the establishment of a process to document and track a student's progress, from removal from an activity due to a suspected concussion, to the return, through graduated steps, to learning and to physical activity

(See the section “Minimum components of the school board policy on concussion”, for further details about each of these requirements.)

The implementation of this policy in all school boards is another important step in creating safe and healthy learning environments in Ontario. It also reinforces the knowledge, skills, and attitudes regarding injury prevention that are developed through expectations in various subjects and disciplines in the Ontario curriculum.

Concussion: definition and diagnosis

Concussion is the term for a clinical diagnosis that is communicated by a physician or a nurse practitioner. School staff, board staff, or volunteers cannot make a concussion diagnosis, but must advise students who are suspected of having sustained a concussion and their parents^{footnote 6[6]} to seek a medical assessment by a physician or a nurse practitioner. The definition of concussion given below is adapted from the definition provided in the concussion protocol in the Ontario Physical Activity Safety Standards in Education.^{footnote 7[7]}

A concussion:

• is a brain injury that causes changes in the way in which the brain functions and that can lead to symptoms that can be physical (e.g., headache, dizziness), cognitive (e.g., difficulty in concentrating or remembering), emotional/behavioural (e.g., depression, irritability), and/or related to sleep (e.g., drowsiness, difficulty in falling asleep)
• may be caused either by a direct blow to the head, face, or neck or by a blow to the body that transmits a force to the head that causes the brain to move rapidly within the skull
• can occur even if there has been no loss of consciousness (in fact, most concussions occur without a loss of consciousness)
• cannot normally be seen by means of medical imaging tests, such as X-rays, standard computed tomography (CT) scans, or magnetic resonance imaging (MRI) scans

Research demonstrates that a concussion can have a significant impact on an individual – cognitively, physically, emotionally, and/or socially.^{footnote 8[8]} Most individuals with a concussion get better in one to four weeks, but, for some, the healing process may take longer.^{footnote 9[9]} It is possible for a concussion to have long-term effects. Individuals may experience symptoms that last for months or even years – symptoms such as headaches, neck pain, or vision problems. Some individuals may even experience lasting changes in their brain that lead to issues such as memory loss, difficulty concentrating, or depression. It should also be noted that if an individual suffers a second concussion before they are free from symptoms sustained from the first concussion, this may lead to “second impact syndrome”, a rare condition that causes rapid and severe brain swelling and often has catastrophic results.^{footnote 10[10]}

Updating the school board policy on concussion

When updating their policy on concussion, school boards are encouraged to consult with school staff; students; parents; teacher federations; principals' associations; education support-staff unions; Indigenous communities, partners, and organizations; and other education partners, as appropriate. School boards are also encouraged to consult with physicians, nurse practitioners, and their local board of health.

The roles and responsibilities of relevant school staff and board staff, as well as students, parents, and school volunteers, must be clearly articulated throughout the school board's policy.

Ophea maintains a concussion protocol, as part of the Ontario Physical Activity Safety Standards in Education (OPASSE). It was developed in partnership with the Ministry of Education; the Ministry of Health; the Ministry of Tourism, Culture and Sport; medical professionals; sport and recreation organizations; health organizations; and educational organizations. The concussion protocol, which is based on current research and evidence, is consistent with Rowan's Law and the Ontario government's Concussion Awareness Resources. The concussion protocol includes detailed information and procedures on:

• concussion prevention
• concussion identification, including the signs and symptoms of a concussion
• the initial response related to a suspected concussion
• the Return to School Plan, which includes information on planning for the return to learning and return to physical activity for students with a diagnosed concussion

The Ministry of Education considers the Ophea concussion protocol to be the minimum standard for risk management practices related to concussion. When developing their policy on concussion, school boards should refer to the Ophea concussion protocol.

Minimum components of the school board policy on concussion

Each school board's policy on concussion is expected to contain, at a minimum, the following components:

Concussion awareness strategies

To establish consistency of concussion awareness across the province, the government of Ontario has developed a set of Concussion Awareness Resources. These resources were developed by leading experts in injury prevention and are available on the government's concussion website. School boards are expected to use these resources to ensure that the information students receive regarding concussions at school is consistent with the information they receive from sport organizations.

The school board policy on concussion must include strategies to receive confirmation, from each of the following individuals, that an approved Concussion Awareness Resource^{footnote 11[11]} was reviewed every school year prior to participation in board-sponsored interschool sports:

• students participating in board-sponsored interschool sports
• parents of students under 18 years of age who are participating in board-sponsored interschool sports
• coaches^{footnote 12[12]} participating in board-sponsored interschool sports
• team trainers^{footnote 13[13]} participating in board-sponsored interschool sports
• officials^{footnote 14[14]} participating in board-sponsored interschool sports

The school board policy on concussion should also include strategies for making the approved Concussion Awareness Resources available – for example, through letters or emails, in a student handbook, and/or on the board website – to students; parents; school and school board staff; volunteers; Indigenous communities, partners, and organizations; organizations that use school facilities such as community sport organizations and licensed child-care providers operating in the school board's schools; as well as relevant community-based organizations, as appropriate.

The school board policy should also contain provisions for connecting student learning about concussions with the curriculum, where relevant. To further support awareness among students, the policy should include implementation plans for an annual concussion awareness event for students, to be held on or around Rowan's Law Day, which occurs on the last Wednesday in September.

Concussion awareness training

Each school board's policy on concussion must include strategies for providing annual concussion training for relevant school staff about the policy itself and the content of the approved Concussion Awareness Resources. School boards are encouraged to provide the concussion training by the last Wednesday in September, Rowan's Law Day, every school year. The policy on concussion should also include provisions for new school staff to access training throughout the school year.

It is expected that school boards, in consultation with teachers' federations, principals' associations, and education workers' unions, will determine the scope of training required to support implementation of their concussion policy, as well as the mode of delivery of the training and any privacy implications that may arise. The scope of training should be consistent with expected duties of school staff, as outlined in the school board policy.

Concussion prevention strategies

The school board policy on concussion must include strategies for preventing and minimizing the risk of sustaining concussions at school.

Concussion Codes of Conduct

The school board policy must establish Concussion Codes of Conduct for several groups participating in board-sponsored interschool sports – students and parents of students under 18 years of age, as well as coaches and team trainers. School boards must review their Concussion Codes of Conduct whenever their concussion policy is reviewed or updated, at a minimum.

The Concussion Codes of Conduct must include the following requirements. Depending on their roles and responsibilities, individuals involved in board-sponsored interschool sports must commit to the relevant requirements below:

• maintaining a safe learning environment
• teaching and/or learning and applying the rules of a physical activity/sport
• implementing the skills and strategies for a physical activity in a proper progression
• fair play and respect for all
• acknowledging and respecting the consequences for prohibited play that is considered high-risk for causing concussions
• providing opportunities to discuss potential issues related to concussions
• recognizing and reporting concussions
• acknowledging the importance of communication between the student, parents, school staff, and any sport organization with which the student is registered
• supporting the implementation of a Return to School Plan for students who have a concussion diagnosis
• prioritizing a student's return to learning as part of the Return to School Plan

Ophea's sample Concussion Codes of Conduct templates, which are geared to the roles and responsibilities of the individuals involved in board-sponsored interschool sports, provide further details.

The school board policy must include strategies to receive confirmation every school year, from each of the following individuals, that the relevant Concussion Code of Conduct was reviewed prior to participation in board-sponsored interschool sports:

• students participating in board-sponsored interschool sports
• parents of students under 18 years of age who are participating in board-sponsored interschool sports
• coaches participating in board-sponsored interschool sports
• team trainers participating in board-sponsored interschool sports

The school board policy on concussion should also include strategies for making the Concussion Codes of Conduct available – for example, through letters or emails, in a student handbook, and/or on the board website – to students; parents; school and school board staff; volunteers; Indigenous communities, partners, and organizations; organizations that use school facilities such as community sport organizations and licensed child-care providers operating in the school board's schools; as well as relevant community-based organizations, as appropriate.

Identification of a Suspected Concussion

School boards should refer to the Ophea concussion protocol when developing the process for the identification of suspected concussions.

The school board policy must establish a process for:

• identifying suspected concussions
• immediately and safely removing a student who is suspected of having sustained a concussion from an activity, regardless of whether the concussion was sustained or is suspected to have been sustained at school or elsewhere
• calling Emergency Medical Services if there is an emergency or if a student has any “red flag” signs and/or symptoms;^{footnote 15[15]}
• informing the student and the student's parents, if the student is under 18 years of age, that removal from the activity was necessary due to a suspected concussion
• advising the student who is suspected of having sustained a concussion and the student's parents, if the student is under 18 years of age, that the student should undergo a medical assessment by a physician or nurse practitioner
• sharing information about the school board's process for supporting a student with a suspected concussion, and the school board's Return to School plan

The school board policy should also clarify that:

• a student who is suspected of having sustained a concussion, or the student's parents, if the student is under 18 years of age, should be encouraged to provide confirmation that the student has undergone a medical assessment by a physician or nurse practitioner to support the student's return to learning
• a student who is suspected of having sustained a concussion, or the student's parents, if the student is under 18 years of age, must provide confirmation that the student has undergone a medical assessment by a physician or nurse practitioner and has not been diagnosed with a concussion, along with confirmation that the student has been medically cleared, before the student can return to full participation in physical activity

Return to School Plan

Each school board's policy on concussion must include a Return to School Plan for students who have been diagnosed with a concussion, regardless of whether the concussion was sustained at school or elsewhere. The Return to School Plan supports both the student's return to learning and their return to physical activity.

The school board's policy, through the Return to School Plan, must:

• establish a process outlining the graduated steps that a student is expected to follow in order to return to learning and to physical activity
• require that the student and the student's parents, if the student is under 18 years of age, be informed of the importance of sharing with the school any medical advice or recommendations received in relation to the student's concussion diagnosis and their return to learning and physical activity
• require that the student and the student's parents, if the student is under 18 years of age, be informed of the importance of disclosing the concussion diagnosis to any relevant organizations with which the student is involved or registered (e.g., sport organizations)
• require that the student or the student's parents, if the student is under 18 years of age, provide confirmation of medical clearance by a physician or nurse practitioner as a prerequisite for the student's return to full participation in physical activity

When these requirements are met, school boards can rely on the information received from a student or the student's parents, if the student is under 18 years of age, in carrying out the school board's responsibilities as part of the Return to School Plan.

When developing the Return to School Plan, school boards should refer to the Ophea concussion protocol. Those developing the plan should note that the return-to-learning process is designed to meet the particular needs of the student, so there is no preset plan of strategies and/or approaches to assist with the return-to-learning activities. The return-to-physical activity process follows an internationally recognized graduated approach.

If a student who is recovering from a concussion is experiencing long-term difficulties that begin to affect their learning, the school board should follow established processes for identifying and documenting instructional approaches and resources that may be required for responding to the student's ongoing learning needs (e.g., individualized classroom accommodations).

Concussion tracking

In accordance with relevant privacy legislation,^{footnote 16[16]} the school board policy on concussion must include a process to document and track a student's progress, from removal from an activity due to a suspected concussion, to the return, through graduated steps, to learning and to physical activity.

In addition, school boards are encouraged to develop a process to track additional information on an ongoing basis in order to inform updates to their concussion policy, as part of the regular policy review cycle.

The Ministry of Education recognizes the sensitive nature of personal health information and reminds school boards to collect, use, and disclose only the relevant diagnostic information needed to fulfil the requirements of this policy and to disclose it only to the parties identified in this policy.

Similarly, when developing a process to document and track concussions, the school board must limit the collection, use, access, and disclosure of personal and health information to that which is reasonably necessary to carry out the school board's concussion identification procedures and Return to School Plan. Personal and health information collected by the school board must be retained, disclosed, and disposed of in accordance with the school board's personal information retention policy.

Implementation

School boards must implement their updated concussion policy no later than January 31, 2020. School boards must ensure that a process is in place to support ongoing implementation of and compliance with their school board policy at the school level.

School board reporting

In accordance with paragraph 27.1 of subsection 8(1) of the Education Act, school boards will be required to report to the Minister of Education, upon implementation and upon request thereafter, on their activities to achieve the requirements outlined in this memorandum.

Support for school boards

The Ontario government has established a concussion website with key partners. It has been developed to provide reliable, evidence-based information on concussion awareness, prevention, identification, and management for parents, children and youth, educators, coaches, athletes, and health care providers. The website includes the government's Concussion Awareness Resources.

The Ministry of Education's concussion web page also provides information and resources for school boards on concussion awareness, prevention, identification, and management. The page includes a link to the Ophea concussion protocol.

The Ontario Public Health Standards: Requirements for Programs, Services, and Accountability (the Standards) identify the minimum expectations for public health programs and services to be delivered by Ontario's boards of health. The Standards include the requirement that public health units reduce the burden of preventable injuries and substance use through consideration of a number of topics, including concussions.