Complete Concussion Management Workplace Accommodation Form

Patient Name:__________________________________Date of Evaluation:_________________________

The patient named above has suffered a mild traumatic brain injury (mTBI), commonly referred to as a concussion, and is currently under the care of this clinic. These injuries can result in significant dysfunction in thinking, focus, attention, memory, and physical capabilities and can also cause a number of symptoms such as headaches, dizziness, and nausea. The patient may need to take a few days off of work completely in order to help with recovery. Upon return, he/she may also need to have some accommodations put in place to help reintegrate back into his/her full responsibilities.

The following workplace accommodations may help in reducing the cognitive (thinking) and physical load, thereby minimizing post-concussion symptoms and allowing the employee to better participate in some of their workplace duties during the injury period. Needed accommodations may vary by course.

Symptoms can wax and wane throughout the day and include, but are not limited to:-Headaches -Sleep difficulties -Cognitive (thinking) difficulties-Nausea -Sensitivity to light -Visual dysfunction-Dizziness -Sensitivity to noise -Environmental sensitivity (commotion)-Fatigue -Fogginess

Prognosis: Based on the patient’s most recent evaluation he/she is:_____ Progressing ______ Stable ______ Regressing

Attendance Restrictions: Full/partial days missed due to concussion symptoms should be medically excused.-Currently the patient has been advised to : ______Remain home from work until:_________________________ ______Attend modified or partial days with the following restrictions (see below) ______Resume full time attendance with the following restrictions (see below) ______Resume full time with no restrictions

______ Limit Screen Time/Admin Work: Concussed patients often find an exacerbation of symptoms with too much exposure to computer monitors and other technological devices. Please allow the employee to find other tasks they can work on if the screen renders them symptomatic. Concussed individuals often have impaired multitasking abilities and increased symptoms with increased cognitive thought.

______ Workload reduction: _____ reduce overall amount of work, (we typically recommend 50-75% reduction in first week); It takes a concussed patient much longer to complete tasks due to increased memory problems and decreased speed of learning. Recovery can be delayed when a patient “pushes through” symptoms. Therefore, it is recommended that “thinking” or cognitive load be reduced. That being said, having the employee still complete tasks at a minimal amount helps them with their recovery process and gradually reintegrates them back into the work environment.

_______ Breaks: Allow the worker to take breaks as needed to control symptom levels. For example, if headache worsens during the day, the patient should retreat to the office lounge or other quiet location to rest. For worse symptoms, he/she may need to be excused from work for the day.

_______ Other Accommodations: ______ Allow employee to wear hat and/or sunglasses (sensitivity to light); _____ change settings (brightness/contrast) on computer screens; ______ Limit physically demanding activity (this can cause symptoms); _______ Avoid busy environments (i.e. if there is a quieter part of the office, relocate them there)_______Other:________________________________________________________________________________________________________

Sincerely,

Name, CredentialsClinic Name, Address, Phone (Please save this file to your computer prior to making any changes)