Comprehensive Initial Pre-Participation Physical Evaluation (CIPPE)

 

Section 1 – Personal and Emergency Information:

 

This section needs to be filled out by the student’s parent/guardian and turned into the Athletic Office for the initial sport only.

 

*If there is any change in personal and emergency information, please contact the athletic office as soon as possible.

 

Section 2 – Certification of Parent/Guardian:

 

This section needs to be filled out by the student’s parent/guardian and turned into the Athletic Office for the initial sport only.

 

PLEASE SIGN BY ALL THE SPORT(S) THEY MAY PARTICIPATE IN DURING THE  YEAR.

 

NOTE:  PLEASE SIGN ON THE LINE BESIDE EACH SPORT THAT YOUR CHILD MAY PARTICIPATE IN DURING THE ENTIRE SCHOOL YEAR. THIS INFORMS THE DOCTOR OF ALL THE SPORTS THE STUDENT MAY PARTICIPATE IN DURING THE SCHOOL YEAR TO HELP WITH THE COMPREHENSIVE PHYSICAL EVALUATION. (Please do not sign all the lines)

 

Section 3 – Health History:

 

This section needs to be filled out by the student’s parent/guardian and turned into the Athletic Office for the initial sport only.

 

Section 4 – PIAA Comprehensive Initial Pre-Participation Physical Evaluation & Certification of Authorized Medical Examiner:

 

Either your family physician or our school doctor should fill out this section.  Please make sure there is an authorized signature and date at the bottom of this page.  Your paperwork will not be accepted without both the signature AND DATE.

 

An “authorized physician” includes:  a licensed physician of medicine or osteopathic medicine, a certified registered nurse practitioner, or a certified physician’s assistant.

 

A valid physician’s signature and date on this section after June 1st for the upcoming school year is valid for all three seasons.  This is all that is required unless there has been a change in the health of the student athlete or he/she has sustained an injury since the initial physical evaluation. 

 

 

 

 

 

 

Section 5 – PIAA Re-Certification by Parent/Guardian:

 

This section needs to be filled out by the student’s parent/guardian and turned into the Athletic Office each time the student is trying out for his/her 2nd or 3rd sport season.  Section 5 is NOT required for the fall season. Section 5  IS REQUIRED for the athletes’ whose (1) first sport is a winter or spring sport season and (2) is dated more not than six weeks prior to the start of the official sport season.

 

If there has been an injury or change in the student’s health since the initial evaluation, meaning they have checked or circled YES to any of the “Supplemental Health History” questions on the bottom of Section 5, the student MUST have a physician fill out Section 6 of the CIPPE form to be cleared to tryout, practice, or play in a subsequent sport season.

 

Section 6 – Certification by licensed physician of medicine or osteopathic medicine:

 

This form must be completed for any student who, subsequent to completion of Sections 1 through 4 of the CIPPE form, required medical treatment from a licensed physician of medicine or osteopathic medicine. This section 6 must be completed at any time following the completion of such medical treatment. Upon completion, the form must be turned in to the principal, or the principal’s designee, of the student’s school.

 

NOTE:

The physician completing Section 6 must first review Section 3, Section 4 and Section 5.

A re-certification is now necessary only for those students who sustain an illness and/or injury that required medical treatment from a licensed physician of medicine or osteopathic medicine since the completion of the CIPPE. In addition, the student is not required to go back to the original Authorized Medical Examiner who performed the CIPPE, nor is the student required to have a complete re-evaluation.

 

If a re-certification is required, the reviewing physician may issue either a "general clearance," with no limitations on further participation, or a "limited clearance," with specified limitations on further participation, as deemed appropriate by the physician.

 

Section 8 - Insurance Waiver Form:

 

This section needs to be filled out and signed by the student-athlete and his/her parent/guardian before the start of the first sport season.  It is required that all Butler Area School District Athletes have the required medical insurance.

 

Section 9 - Eligibility Questionnaire Form:

 

This section needs to be filled out and signed by the student athlete and his/her parent/guardian before the first sport season. If a question requires a call to the athletic office, please do so immediately so that we may verify eligibility. 

 

 

 

 

Explanation of Sections Needed for Each Sport Physical

 

START DATE FOR PIAA WINTER SEASON IS NOVEMBER 19, 2010.

START DATE FOR PIAA SPRING SEASON IS MARCH 7, 2011.

 

INITIAL SPORT PHYSICALS (Represents the first sport an athlete intends to play in a school year)

 

Must include:    Section 1

                                    Section 2-  Sign all sports that your child may participate in during the year

                                    Section 3

                                    Section 4

                                    Section 5 * Refer back to Section 5 – PIAA Re-Certification by Parent/Guardian

                                                    * Section 5 is not required to participate in a fall sport

Section 8 – Insurance Waiver Form

                                    Section 9 – Eligibility Questionnaire Form

                                    Section 10- NovaCare Form

*EXAMPLE: If you had the physical done in the summer for a winter or spring sport, please wait to complete Section 5 until 14 days before the start of the winter season which is November 9, 2010; the spring season start date is Feburary 21, 2011.

 

RE-CERTIFICATION PHYSICALS – WITHOUT INJURIES AS WELL AS PHYSICALS DATED 14 DAYS PRIOR TO THE START OF THE PIAA SEASON

 (Represents all subsequent sports’ seasons in a school year provided there have been no injuries to the athlete from the initial evaluation. This is also required if there has been a lapse of time between the comprehensive physical (CIPPE) and the first day of official practice of more than six weeks. 

 

Must include:                *Section 5 (if checked yes to any questions in this section, you must have a physician complete section 6; please follow the Re-Certification of Physicals with Injuries below).

 

 

RE-CERTIFICATION PHYSICALS - WITH INJURIES

(Represents all subsequent sports’ seasons in a school year when the athlete has sustained an injury or change in health since the initial evaluation. Please schedule an appointment as soon as possible so there is not a delay in being eligible for the next sport season).

 

Must include:                *Section 5

*Section 6 - Requires a doctor’s signature and updated date

*If you are going to a different physician than the one who performed the original physical, you must take with you Sections 1, 2, 3, 4, and 5 to the appointment.