Understanding the CIPPE

Since it first made its debut following the May 25, 2006, meeting of the PIAA Board of Directors, the Comprehensive Initial Pre-Participation Physical Evaluation form ("CIPPE Form"), has been amended several times in response to recommendations from a variety of PIAA constituencies. Unfortunately, the many changes in response to those recommendations have left some member school administrators, medical professionals and parents second guessing themselves as to whether a physical performed by a licensed physician of medicine or osteopathic medicine, a physician assistant certified, a certified registered nurse practitioner, or a school nurse practitioner (Authorized Medical Examiner or "AME") was valid for an upcoming sports season. To better understand the CIPPE process and Form, it may be useful to examine the rationale behind the recent changes and some of the questions relating to the current Form.

BACKGROUND

For many, many years, PIAA has had a "pre-participation physical evaluation" requirement for participation in interscholastic athletics. That requirement, found in ARTICLE V, HEALTH, of the PIAA By-Laws, was not specific as to what level of examination was expected. The form completed by an AME was general, and required only certification that the examiner had "performed a preparticipation physical evaluation and [found] that the student is physically fit to commence Practice and participate in Contests...." No health history was required nor were there any guidelines presented as to what type of examination was required. Many schools arranged for "gymnasium physicals" for entire Teams in which individual examinations were completed in a few minutes, or less.

The longstanding approach to pre-participation examinations began to change in December 2001, when the PIAA Board of Directors approved the use of an alternative examination form, the PA Governor's Council on Physical Fitness & Sports Pre-Participation Sports Physical Examination form ("Governor's Council Form"). That form was considerably more extensive than the PIAA Physician's Certificate.

In 2005, at the request of the PIAA Sports Medicine Advisory Committee, the Board of Directors began to look more closely at the pre-participation examination and recertification requirements. Extensive investigation and discussion occurred over the next year, with the focus being on whether a much more comprehensive examination should be required.

In May 2006, a major overhaul of ARTICLE V, HEALTH, of the By-Laws was approved by the Board of Directors. The revised provision now sets forth a preamble outlining the need and approach relating to the pre-participation physical examination, and recertification requirements. For the first time, students were given the option of completing a traditional examination, now identified as the "Pre-Participation Physical Evaluation," or "PPE," or undergoing a single comprehensive sport physical examination annually (known as the "Comprehensive Pre-Participation Physical Evaluation," or "CIPPE"), although some changes in health history would require a follow-up recertification by an AME. In order to provide schools with ample time to incorporate the new CIPPE Form into practice, the amendment provided for a two-year phase out period of both the widely used PIAA Parent/Physician Certificate and the recently added Governor's Council Form. However, beginning June 1, 2008, the new CIPPE Form would be the only valid form for the completion of sports physicals.

The May 2006 changes were approved by the barest of margins. On a final reading, 2/3 of the Board of Directors (or 20 of the 30 members) must approve an amendment to the By-Laws. The revisions to ARTICLE V received 20 votes. The dissenters expressed concern primarily over two aspects of the changes. The first concerned issues relating to recertification, and the second, the timing for completion of the new form. Each was addressed in the coming months.

The first concern was whether recertification should be required for students undergoing CIPPEs and, if so, under what circumstances. The PIAA Sports Medicine Advisory Committee suggested that at least some process of review was needed to ensure that a student who was injured or became ill after a CIPPE, be reassessed to determine whether he or she was able to participate in subsequent sports. To address the concerns, the Board of Directors again amended ARTICLE V, HEALTH, of the PIAA By-Laws, at the January 25, 2007, meeting to require that a Parent/Guardian complete a supplemental health history (included in Section 5 of the CIPPE). A review of this form is then made by the school's Principal, or Principal's designee, who then makes a decision as to whether the student will be required to be cleared by an AME prior to subsequent participation. This check ensures that both the student's parent(s) and the school have at least reviewed the student's condition before deciding whether or not a further examination is needed.

The other remaining concern was that of the timing of the CIPPE. The new language provided for CIPPE Forms to be completed "...at any time and shall be valid for one year from the date of such CIPPE." Although this new language solved many worries regarding HMO and insurance users, which typically fund only a single comprehensive physical evaluation annually, it created concerns for school athletic administrators. By permitting CIPPEs to be valid for 365 days, administrators were now required to track each individual's CIPPE date and determine when a new physical would be required. Additionally, it also opened the door for students to potentially receive a physical nine months prior to their initial participation in a sport, without a standard reporting procedure in place for changes to their health history. The timing dilemma brought about reluctance in the medical community to certify student participation in a sport that was no longer in close proximity to the examination. In many schools that still provide for sport physicals, this was a real dilemma.

The final pieces of the CIPPE puzzle were put in place on recommendations from both the PIAA Sports Medicine Advisory Committee and the Pennsylvania State Athletic Directors Association (PSADA) Delegate Assembly, to clarify the timing of the CIPPE. Both groups recommended to the Board of Directors that they tighten the standards for CIPPEs so that no student could be eligible for more than three consecutive sport seasons following completion of a CIPPE. The Board again amended ARTICLE V, HEALTH, of the PIAA By-Laws, at its May 23 and 24, 2007, meeting stating just that. However, both groups, as well as constituencies represented at the PIAA Summer Workshop, requested further clarification that mandated that no CIPPE be given prior to June 1, for the next school year, and that each physical, regardless of time completed, would expire as of May 31 of the next school year. These recommendations reflected the ongoing cooperation between the PIAA Board of Directors, PIAA Sports Medicine Advisory Committee, and the PSADA Delegate Assembly, when dealing with physical examinations. Each group has long supported the ideal of June 1 as a cutoff for sport physicals, for the next school year, for three main reasons:

1. CIPPEs for the following year may be provided by the school prior to students leaving for summer break, but after completion of most sports from the prior sports year,
2. the CIPPE is still completed in reasonable proximity to the start of the fall sport season, and
3. the administrative ease in determining eligibility for all student-athletes to start a sports season.

The Board of Directors finalized language reflecting the June 1 recommendation at its July 25, 2007 meeting.

ADDITIONAL ISSUES RELATING TO APPLICATION OF THE CIPPE

1. CIPPE'S FROM THE 2006-2007 SCHOOL YEAR: The various and recent changes undoubtedly still leave some school administrators wondering whether CIPPEs completed prior to June 1, 2007, are valid for the 2007-2008 school year. The answer is "yes," since they are considered valid for one calendar year from the date of their satisfactory completion. However, to be acceptable, each of the CIPPEs completed prior to June 1, 2007 must meet all of the following conditions: (1) any examination completed prior to June 1, 2007 must have been completed on the CIPPE Form; (2) the parent/guardian must certify in Section 5 that there has not been a change in their student-athlete's health history since their student-athlete's CIPPE was performed; and (3) the CIPPE is only be valid for three consecutive sport seasons.

2. ELIMINATION OF THE PPE FORMS: As further clarification moving forward for the 2008-2009 school year: (1) only the CIPPE Form will be valid for sports participation. The Parent/Physician Certificate and Governor's Council Form will no longer be valid, as of June 1, 2008; (2) only CIPPE's performed on or after June 1 of each year will be valid for sports participation; (3) CIPPE's shall be effective, regardless of when performed during the school year, until the next May 31st; and (4) after completion of the CIPPE, the student's parent/guardian shall be required to complete and submit, to the student's Principal, or Principal's designee, Section 5 of the CIPPE Form prior to the student's subsequent participation in another sports season.

Although ARTICLE V, HEALTH, of the PIAA By-Laws, has been recently amended several times, the Board of Directors' purpose in doing so was driven by the need to respond to all constituencies (member schools, medical community, and parents) involved in this process and to improve the pre-participation physical process. Each change was made in hopes of simplifying the process of obtaining sports physicals, without compromising a primary purpose of the organization, which is to "organize, develop, and direct an interscholastic athletic program which will promote, protect, and conserve the health and physical welfare of all participants."

For the latest copy of ARTICLE V, HEALTH, of the PIAA By-Laws, and the CIPPE Form, click on the link provided above or access the PIAA Handbook at http://www.piaa.org/resources/handbook.