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IHSAA Physical Form 2017

Click here to download: IHSAA Physical Form - 2017

PRE-PARTICIPATION PHYSICAL
EVALUATION FORM (PPE)

The IHSAA Pre-participation Physical Evaluation (PPE) is the fi rst and most important step inproviding for the well-being of Indiana’s high school athletes. The form is designed to identify risk factors prior to athletic participation by way of a thorough medical history and physical examination. The IHSAA, under the guidance of the Indiana State Medical Association’s Committee on Sports Medicine, requires that the PPE Form be signed by a physician (MD or DO) holding an unlimited license to practice medicine, a nurse practitioner (NP) or a physician assistant (PA). In order to assure that these rigorous standards are met, both organizations endorse the following requirements for completion of the PPE Form:

1. The most current version of the IHSAA PPE Form must be used and may not be altered or modified in any way. (available for download at www.ihsaa.org)

2. The PPE Form must be signed by a physician (MD or DO) holding an unlimited license to practice medicine, a nurse practitioner (NP) or a physician assistant (PA) only after the medical history is reviewed, the examination performed, and the PPE Form completed in its entirety. No pre-signed or pre-stamped forms will be accepted.

3. SIGNATURES

The signature must be hand-written. No signature stamps will be accepted.

The signature and license number must be affi xed on page two (2).

The parent signatures must be affi xed to the form on pages one (1) and four (4).

The student-athlete signature must be affi xed to pages one (1) and four (4).

Your cooperation will help ensure the best medical screening for Indiana’s high school athletes.

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