Health Record and Questionnaire Sports Pre-participation and Recertification Forms
24 P.S. § 5-511
Date of Issue: July 1, 2002
Date of Review: August 1, 2010
This BEC explains the protocol for the pre-participation and recertification physical evaluation of students participating in interscholastic athletics that are within the jurisdiction of the Pennsylvania Interscholastic Athletic Association, Inc.
Section 5-511 of the School Code provides that the local school board “shall prescribe, adopt, and enforce such reasonable rules and regulations as it may deem proper, regarding (1) the management, supervision, control, or prohibition of exercises, athletics, or games of any kind….” In addition, the Pennsylvania Interscholastic Athletic Association, Inc. (PIAA) requires all students who wish to participate in an interscholastic sport to have a comprehensive initial pre-participation physical evaluation (CIPPE) by an Authorized Medical Examiner. PIAA defines an Authorized Medical Examiner as a licensed physician of medicine or osteopathic medicine, a certified physician assistant, a certified registered nurse practitioner or a school nurse practitioner.
Effective June 1, 2008, only the PIAA Comprehensive Initial Pre-Participation Physical Evaluation Form (CIPPE Form) may be used to satisfy the requirements of ARTICLE IV, CONSENT OF PARENT OR GUARDIAN, of the PIAA By-Laws; and ARTICLE V, HEALTH, of the PIAA By-Laws. The previously used "Parent/Physician (blue) Cards" and the "Governor’s Council on Physical Fitness and Sports Pre-Participation Sports Physical Evaluation" are no longer acceptable,
Beginning the 2008-2009 school year, every student athlete seeking to participate in sports within PIAA's jurisdiction must begin using the CIPPE Form.
Sections 1, 2, 3: The student's parent or guardian must complete Section 1: Personal and Emergency Information and complete and sign Section 2: Certification of Parent/Guardian and Section 3: Health History of the CIPPE Form.
Section 4: An Authorized Medical Examiner performing a student’s physical evaluation prior to participation in a sports program must then complete Section 4: PIAA Comprehensive Initial Pre-participation Physical Evaluation and Certification of Authorized Medical Examiner.
Section 5: Re-certification by Parent/Guardian, Supplemental Health History, is designed for students who participate in more than one sport in a school year. This Section is to be completed and signed by the parent/guardian.
Section 6: PIAA Comprehensive Pre-Participation Physical Re-Evaluation and Re-Certification by an Authorized Medical Examiner is completed by the Authorized Medical Examiner if a physical evaluation is required prior to re-certification.
Section 7: CIPPE Minimum Wrestling Weight must be completed by an Authorized Medical Examiner prior to the participation of any student in interscholastic wrestling.
A CIPPE may be performed no earlier than June 1st; and, regardless of when performed during the school year, remains effective only until the next May 31st.
Although the CIPPE Form is completed in connection with the sports pre-participation physical, the CIPPE Form may also be used to satisfy the 11th grade mandated physical examination requirements.
The district may add the school name and address to the top of these forms, and make as many copies as necessary.
24 P.S. §5-511
The PIAA Sports Medicine Guidelines, which includes the PIAA Comprehensive Initial Pre-Participation Physical Evaluation Form and the Guidelines for Medical Coverage for Athletic Events, is included with this BEC.
PIAA Comprehensive Initial Pre-Participant Physical Evaluation Form (CIPPE)
PIAA Sports Medicine Guidelines
School Health Programs
Bureau of Teaching and Learning Support
Pennsylvania Department of Education
333 Market Street, 8th Floor
Harrisburg, PA 17126-0333
Phone: (717) 772-0067