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1 Diabetes Medical Management Plan This plan as well as school medication forms, self authorization and dietary forms should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel. Student s Name: of Plan: of Birth: Diagnosis: Student with diabetes is allowed to carry diabetes supplies at school, test blood sugar levels wherever and whenever needed and take immediate corrective action, all in accordance with this diabetes care plan. Diabetes supplies may be kept wherever student is located or in accessible location. Overall goal is to keep student in classroom to facilitate class attendance and participation. Daily Procedures Blood Glucose Monitoring: Insulin Injection: Insulin Pump: Ketones: Diet/Carb Counting: Breakfast Lunch until then supervise until then supervise until then supervise until then supervise until then supervise 1

2 I give permission for student to determine correct time of administration, calculate amount of carbs consumed, calculate dose of insulin and administer own insulin Changes and updates to student's diabetic orders may be communicated in writing to school by parent Blood Glucose Monitoring Check blood sugar before lunch or at any time student exhibits symptoms of low blood sugar Parent may request increased testing as necessary Before exercise After exercise End of school day When student exhibits symptoms of high blood sugar Academic Testing: 2 hours after meal Other (explain): Insulin Humalog Novolog Apidra Other: Insulin is given subcutaneously Insulin / carbohydrate ratio for meals snacks unit/ grams carbohydrate. High blood sugar correction ratio or sliding scale for meals or as ordered by MD is unit for every mg/dl above or units if blood glucose is less than mg/dl units if blood glucose is to mg/dl units if blood glucose is to mg/dl units if blood glucose is to mg/dl units if blood glucose is greater than mg/dl Insulin Pump: Parents/Student is responsible for troubleshooting alarms and malfunctions Lunch Procedure Option: Check blood sugar Count carbs Eat Give insulin coverage after meal Lunch Procedure Option: Check blood sugar Count carbs Give insulin coverage before meal Eat 2

3 Diet Student will eat breakfast at school and will require supervision Snack before exercise? Yes Depending on blood sugar results Scheduled snack Time: Snack: Carbohydrate amount: Instructions for when food is provided to the class (e.g., as part of a class party): Hypoglycemia (Low Blood Sugar) Usual symptoms of hypoglycemia: Hunger Sweaty Trembling Pale Inability to concentrate Confusion Irritability Sleepiness Headache Crying Slurred speech Poor coordination Personality change Complains of feeling low Other: Treatment of hypoglycemia: If blood sugar below mg/dl, provide 15 grams of carbohydrate snack. Recheck blood sugar in 15 minutes. Provide additional snack if sugar is not rising. other Student should not exercise if blood glucose level is below 70 mg/dl or. Parent will be responsible for low blood sugar snacks. DO NOT LEAVE STUDENT ALONE OR ALLOW TO LEAVE CLASSROOM ALONE! 1 mg Glucagon should be given IM or SC if the student is unconscious, having a seizure (convulsion), or unable to swallow. Turn student on their side, then, call 911 (or other emergency assistance) and the parents/guardian. 3

4 Hyperglycemia (High Blood Sugar) Usual symptoms of hyperglycemia: Frequent urination Excessive thirst Sleepiness Blurred vision Inability to concentrate Nausea Vomiting Other Treatment of hyperglycemia: Insulin correction dose as written by physician Insulin correction, only at breakfast and/or lunch Recheck blood sugar in 60 minutes to see if blood sugar is going down Encourage student to drink water Allow bathroom privileges If blood sugar above or student feeling unwell or at request of parent, urine should be checked for ketones Student should not exercise if blood glucose level is above 400 mg/dl or or if moderate to large urine ketones are present. Call parent if symptoms worsen or student begins vomiting, has a fever or problems with insulin pump. Signatures: This Diabetes Medical Management Plan has been approved by: Student s Physician/Health Care Provider I give permission to the school nurse, trained diabetes personnel, and other designated staff members of School to perform and carry out the diabetes care tasks as outlined by s Diabetes Medical Management Plan. I also consent to the release of the information contained in this Diabetes Medical Management Plan to all staff members and other adults who have custodial care of my child and who may need to know this information to maintain my child s health and safety. Acknowledged and received by: Student s Parent/Guardian Student s Parent/Guardian 4

5 DIABETES SELF-MEDICATION AUTHORIZATION FORM SCHOOL YEAR: Student s Name: Phone: Revised School: Grade: D.O.B.: DIABETES SUPPLIES: Blood sugar monitor, blood sugar strips, Lancet Device, Lancets, Insulin pump supplies, Glucose Tablets, Insulin syringe DIRECTIONS FOR DIABETES SUPPLIES: has Diabetes that necessitates selfmonitoring and self managing. I have reviewed the blood glucose testing protocol and judge that this student has the knowledge and maturity to self-manage this blood glucose monitor safely and correctly. I have Physician read Protocol Signature for blood glucose testing and I judge that my son/daughter named above has sufficient I I understand that my son/daughter must comply with the following: He/she must keep the monitor in his/her possession at all times and shall not leave it in a place accessible to other students The students shall not offer, nor allow any use or possession of his/her blood glucose monitor to another student. The student shall act in a responsible and discreet manner concerning his/her blood glucose monitor All sharp objects and contaminated materials used for testing shall be stored in the student s blood glucose kit or disposed of in a biohazard container located in a secure location in the school. Snacks or glucose tablets will be allowed in the classroom at regular intervals based on individual need and to alleviate a low-blood episode. I understand that the only liability that the school can assume is to comply with terms of this protocol. I understand that the school can assume no liability for monitoring the self-administration including the frequency or failure to monitor when necessary. I understand that the principal in consultation with nurse is final of student s compliance with these guidelines. Parent/Guardian Signature

6 Medical Statement for Students with Special Nutritional Needs for School Meals Part A (To be completed by Parent/Guardian) Name of Student: (Last) (First) (Middle) Student ID # School Grade Will student eat breakfast at school? Will student eat lunch at school? Will student eat snack in the after school program? Name of Parent/Guardian: Mailing Address: City: State/Zip: Phone number(s): (W) (H) (Cell) Does Does the child have an identified disability? If yes Describe the major life activities affected by the disability: Does the child have special nutritional or feeding needs? If Yes, have a licensed physician complete Part B of this form and sign it. If the child does not have an identified disability, does the child have special nutritional or feeding needs? If Yes, have a licensed physician or recognized medical authority complete Part B of this form and sign it. Signature of Parent/guardian Printed name Telephone number Specify any dietary restrictions or special diet: Part B Diet Order (To be completed by Physician) List any foods that cause food allergies or intolerances that should be avoided: If student has life threatening allergies, check appropriate box(es): ingestion contact inhalation Designate consistency requirements for food: Designate consistency requirement for liquids: Blenderized Liquid Puree Mechanical Soft Soft Honey-thick Spoon-thick For any special diet, list specific foods to be omitted and suggested substitutions. You may attach a separate page with additional information. A. Foods To Be Omitted B. Suggested Substitutions Thin Nectar-thick Indicate any other comments about the child s eating or feeding patterns: Signature of physician/medical authority* Printed name Telephone number *A licensed physician s signature is required for participants with a disability. For participants without a disability, a licensed physician or medical authority must sign the form. Child Nutrition Services Notes: Part C (To be completed by Child Nutrition Services) CN Administrator Signature: : In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C or call (800) or (202) (T)

7 PHYSICIAN S SCHOOL MEDICATION FORM Revised Name of School: Name of Student: GRADE: AGE: The above named person is a patient of mine and is currently under my medical care. Due to a medical condition the medication listed below needs to be (given, taken, injected) during regular school day according to the following protocol: Medication: INSULIN Time to be given: Before Lunch or as prescribed Directions for administering medication: May be kept: with student, in classroom, refrigerator, med cart If an emergency situation occurs during the school day, or if the pupil becomes ill, school officials are to: a) Contact me at my office: b) Take child immediately to the emergency room: c) Other option: The medication for this pupil from me will be properly labeled and will carry my name as the prescribing physician. Physician s Signature : RELEASE OF LIABILITY FORM I,, the parent and/or legal guardian of, enrolled at. Name of Child Name of School Realizing the importance of administering medication to my child as prescribed by the child s physician, do hereby agree to relieve designated school personnel of any liability from any potential ill effects as a result of their injecting or giving my child medication prescribed by the child s physician. I have discussed this with my physician and/or legal counsel (lawyer) and realize its ramifications and thoroughly understand the meanings of these statements. I consent for the medical provider to disclose health or medical information regarding medication prescribed. I understand that I may revoke this consent at any time, except to the extent action has been taken in reliance on it. This consent is valid until I revoke it in writing or for the term of the school year. Parent or Guardian s Signature Principal s Signature FOR SCHOOL USE ONLY Physician s School Medication Form Expires: Please be reminded form will expire one (1) year from date of Physician s signature.

8 PHYSICIAN S SCHOOL MEDICATION FORM Revised Name of School: Name of Student: GRADE: AGE: The above named person is a patient of mine and is currently under my medical care. Due to a medical condition the medication listed below needs to be (given, taken, injected) during regular school day according to the following protocol: Medication: GLUCAGON_INJECTION: 1 mg subcutaneously (beneath skin) or Intramuscular (within a muscle) Time to be given: Severe low blood sugar, if student is unconscious or having a seizure Directions for administering medication: Roll student on side in case of vomiting_ May be kept with student, in classroom, refrigerator or med cart If an emergency situation occurs during the school day, or if the pupil becomes ill, school officials are to: a) Contact me at my office: b) Take child immediately to the emergency room at: c) Other option: The medication for this pupil from me will be properly labeled and will carry my name as the prescribing physician. Physician s Signature: : RELEASE OF LIABILITY FORM I,, the parent and/or legal guardian of, enrolled at. Name of Child Name of School Realizing the importance of administering medication to my child as prescribed by the child s physician, do hereby agree to relieve designated school personnel of any liability from any potential ill effects as a result of their injecting or giving my child medication prescribed by the child s physician. I have discussed this with my physician and/or legal counsel (lawyer) and realize its ramifications and thoroughly understand the meanings of these statements. I consent for the medical provider to disclose health or medical information regarding medication prescribed. I understand that I may revoke this consent at any time, except to the extent action has been taken in reliance on it. This consent is valid until I revoke it in writing or for the term of the school year. Parent or Guardian s Signature Principal s Signature FOR SCHOOL USE ONLY Physician s School Medication Form Expires: Please be reminded form will expire one (1) year from date of Physician s signature.