School Medication Authorization Form. School Grade Teacher. Emergency Phone No: To be completed by the student's physician: Name of Medication:
|
|
- Peter Bradley
- 5 years ago
- Views:
Transcription
1 Schl Medicatin Authrizatin Frm Student's Name Address Birth Date Hme Phne Schl Grade Teacher Emergency Phne N: T be cmpleted by the student's physician: Name f Medicatin: Dsage Frequency Time t be given in schl Date f prescriptin Date f rder Discntinuatin date Diagnsis requiring medicatin Intended effect f this medicatin Must this medicatin be administered during the schl day in rder t allw the child t attend schl r t address the student's medicatin cnditin? Expected side effects, if any: Time interval fr re-evaluatin: Other medicatins student is receiving: Physician's name signature: Physician's name print: Address: Office Phne: Emergency Phne: Date: Medicatin/treatment rders are included in attached plan. DISTRICT HEALTH SERVICES Greenbrk Spring Wd Waterbury Phne Phne Phne Fax Fax Fax
2 I, (parent), cnfirm that I am primarily respnsible fr administering medicatin t my child. Hwever, in the event that I am unable t d s r in the event f a medical emergency, I hereby authrize Keeneyville Schl District #20 and its emplyees and agents, in my behalf and stead, t administer r t attempt t administer t my child (r t allw my child t self-administer, while under the supervisin f the emplyee and agents f the Schl District), lawfully prescribed medicatin in the manner described abve. I ACKNOWLEDGE THAT IT MAY BE NECESSARY FOR THE ADMINISTRATION OF MEDICATION TO MY CHILD TO BE PERFORMED BY AN INDIVIDUAL OTHER THAN A SCHOOL NURSE, AND SPECIFICALLY CONSENT TO SUCH PRACTICES. I further acknwledge and agree that, when the lawfully prescribed medicatin is s administered r attempted t be administered. I waive any claims I might have against the Schl District, its emplyees and agents arising ut f the administratin f said medicatin. In additin, I agree t hld harmless and indemnify the Schl District, its emplyees and agents, either jintly r severally, frm and against any and all claims, damages, causes f actin r injuries incurred r resulting frm the administratin r attempts at administratin f said medicatin. (PARENT'S/GUARDIAN'S SIGNATURE) (DATE) DISTRICT HEALTH SERVICES Greenbrk Spring Wd Waterbury Phne Phne Phne Fax Fax Fax
3 Diabetes Medical Management Plan (DMMP) This plan shuld be cmpleted by the student s persnal diabetes health care team, including the parents/guardian. It shuld be reviewed with relevant schl staff and cpies shuld be kept in a place that can be accessed easily by the schl nurse, trained diabetes persnnel, and ther authrized persnnel. Date f Plan: This plan is valid fr the current schl year: - Student s Name: Date f Birth: Date f Diabetes Diagnsis: type 1 type 2 Other Schl: Schl Phne Number: Grade: Hmerm Teacher: Schl Nurse: Phne: Tls CONTACT INFORMATION Mther/Guardian: Address: Telephne: Hme Wrk Cell: Address: Father/Guardian: Address: Telephne: Hme Wrk Cell: Address: Student s Physician/Health Care Prvider: Address: Telephne: Address: Emergency Number: Other Emergency Cntacts: Name: Relatinship: Telephne: Hme Wrk Cell: Helping the Student with Diabetes Succeed 99
4 Diabetes Medical Management Plan (DMMP) Page 2 Checking Bld Glucse Target range f bld glucse: mg/dl mg/dl Other: Check bld glucse level: Befre lunch Hurs after lunch 2 hurs after a crrectin dse Mid-mrning Befre PE After PE As needed fr signs/symptms f lw r high bld glucse As needed fr signs/symptms f illness Befre dismissal Other: Preferred site f testing: Fingertip Frearm Thigh Other: Brand/Mdel f bld glucse meter: Nte: The fingertip shuld always be used t check bld glucse level if hypglycemia is suspected. Student s self-care bld glucse checking skills: Independently checks wn bld glucse May check bld glucse with supervisin Requires schl nurse r trained diabetes persnnel t check bld glucse Cntinuus Glucse Mnitr (CGM): Yes N Brand/Mdel: Alarms set fr: (lw) and (high) Nte: Cnfirm CGM results with bld glucse meter check befre taking actin n sensr bld glucse level. If student has symptms r signs f hypglycemia, check fingertip bld glucse level regardless f CGM. HYPOGLYCEMIA TREATMENT Student s usual symptms f hypglycemia (list belw): If exhibiting symptms f hypglycemia, OR if bld glucse level is less than mg/dl, give a quick-acting glucse prduct equal t grams f carbhydrate. Recheck bld glucse in minutes and repeat treatment if bld glucse level is less than mg/dl. Additinal treatment: 100
5 Diabetes Medical Management Plan (DMMP) Page 3 HYPOglYCEMIA TREATMENT (Cntinued) Fllw physical activity and sprts rders (see page 7). If the student is unable t eat r drink, is uncnscius r unrespnsive, r is having seizure activity r cnvulsins (jerking mvements), give: Glucagn: 1 mg 1/2 mg Rute: SC IM Call 911 (Emergency Medical Services) and the student s parents/guardian. Cntact student s health care prvider. Site fr glucagn injectin: arm thigh Other: HYPERGLYCEMIA TREATMENT Student s usual symptms f hyperglycemia (list belw): Tls Check Urine Bld fr ketnes every hurs when bld glucse levels are abve mg/dl. Fr bld glucse greater than mg/dl AND at least hurs since last insulin dse, give crrectin dse f insulin (see rders belw). Fr insulin pump users: see additinal infrmatin fr student with insulin pump. Give extra water and/r nn-sugar-cntaining drinks (nt fruit juices): unces per hur. Additinal treatment fr ketnes: Fllw physical activity and sprts rders (see page 7). Ntify parents/guardian f nset f hyperglycemia. If the student has symptms f a hyperglycemia emergency, including dry muth, extreme thirst, nausea and vmiting, severe abdminal pain, heavy breathing r shrtness f breath, chest pain, increasing sleepiness r lethargy, r depressed level f cnsciusness: Call 911 (Emergency Medical Services) and the student s parents/ guardian. Cntact student s health care prvider. Helping the Student with Diabetes Succeed 101
6 Diabetes Medical Management Plan (DMMP) page 4 INSULIN THERAPY Insulin delivery device: syringe insulin pen insulin pump Type f insulin therapy at schl: Adjustable Insulin Therapy Fixed Insulin Therapy N insulin Adjustable Insulin Therapy Carbhydrate Cverage/Crrectin Dse: Name f insulin: Carbhydrate Cverage: Insulin-t-Carbhydrate Rati: Lunch: 1 unit f insulin per grams f carbhydrate Snack: 1 unit f insulin per grams f carbhydrate Carbhydrate Dse Calculatin Example Grams f carbhydrate in meal Insulin-t-carbhydrate rati = units f insulin Crrectin Dse: Bld Glucse Crrectin Factr/Insulin Sensitivity Factr = Target bld glucse = mg/dl Crrectin Dse Calculatin Example Actual Bld Glucse Target Bld Glucse = units f insulin Bld Glucse Crrectin Factr/Insulin Sensitivity Factr Crrectin dse scale (use instead f calculatin abve t determine insulin crrectin dse): Bld glucse t mg/dl give units Bld glucse t mg/dl give units Bld glucse t mg/dl give units Bld glucse t mg/dl give units 102
7 Diabetes Medical Management Plan (DMMP) page 5 INSUlIN THERAPY (Cntinued) When t give insulin: Lunch Carbhydrate cverage nly Carbhydrate cverage plus crrectin dse when bld glucse is greater than mg/dl and hurs since last insulin dse. Other: Snack N cverage fr snack Carbhydrate cverage nly Carbhydrate cverage plus crrectin dse when bld glucse is greater than mg/dl and hurs since last insulin dse. Other: Crrectin dse nly: Fr bld glucse greater than mg/dl AND at least hurs since last insulin dse. Other: Tls Fixed Insulin Therapy Name f insulin: Units f insulin given pre-lunch daily Units f insulin given pre-snack daily Other: Parental Authrizatin t Adjust Insulin Dse: Yes N Parents/guardian authrizatin shuld be btained befre administering a crrectin dse. Yes N Parents/guardian are authrized t increase r decrease crrectin dse scale within the fllwing range: +/- units f insulin. Yes N Parents/guardian are authrized t increase r decrease insulin-tcarbhydrate rati within the fllwing range: units per prescribed grams f carbhydrate, +/- grams f carbhydrate. Yes N Parents/guardian are authrized t increase r decrease fixed insulin dse within the fllwing range: +/- units f insulin. Helping the Student with Diabetes Succeed 103
8 Diabetes Medical Management Plan (DMMP) page 6 INSUlIN THERAPY (Cntinued) Student s self-care insulin administratin skills: Yes Yes Yes N N N Independently calculates and gives wn injectins May calculate/give wn injectins with supervisin Requires schl nurse r trained diabetes persnnel t calculate/give injectins ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP Brand/Mdel f pump: Type f insulin in pump: Basal rates during schl: Type f infusin set: Fr bld glucse greater than mg/dl that has nt decreased within hurs after crrectin, cnsider pump failure r infusin site failure. Ntify parents/guardian. Fr infusin site failure: Insert new infusin set and/r replace reservir. Fr suspected pump failure: suspend r remve pump and give insulin by syringe r pen. Physical Activity May discnnect frm pump fr sprts activities Yes N Set a temprary basal rate Yes N % temprary basal fr hurs Suspend pump use Yes N Student s self-care pump skills: Independent? Cunt carbhydrates Yes N Blus crrect amunt fr carbhydrates cnsumed Yes N Calculate and administer crrectin blus Calculate and set basal prfiles Calculate and set temprary basal rate Change batteries Discnnect pump Recnnect pump t infusin set Prepare reservir and tubing Insert infusin set Yes Yes Yes Yes Yes Yes Yes Yes N N N N N N N N Trublesht alarms and malfunctins Yes N
9 Diabetes Medical Management Plan (DMMP) page 7 OTHER DIABETES MEDICATIONS Name: Dse: Rute: Times given: Name: Dse: Rute: Times given: MEAL PLAN Meal/Snack Time Carbhydrate Cntent (grams) Breakfast t Mid-mrning snack t Lunch t Mid-afternn snack t Other times t give snacks and cntent/amunt: Instructins fr when fd is prvided t the class (e.g., as part f a class party r fd sampling event): Special event/party fd permitted: Parents/guardian discretin Student discretin Student s self-care nutritin skills: Yes N Independently cunts carbhydrates Yes N May cunt carbhydrates with supervisin Yes N Requires schl nurse/trained diabetes persnnel t cunt carbhydrates Tls PHYSICAL ACTIVITY AND SPORTS A quick-acting surce f glucse such as glucse tabs and/r sugar-cntaining juice must be available at the site f physical educatin activities and sprts. Student shuld eat 15 grams 30 grams f carbhydrate ther befre every 30 minutes during after vigrus physical activity ther If mst recent bld glucse is less than mg/dl, student can participate in physical activity when bld glucse is crrected and abve mg/dl. Avid physical activity when bld glucse is greater than mg/dl r if urine/ bld ketnes are mderate t large. (Additinal infrmatin fr student n insulin pump is in the insulin sectin n page 6.) Helping the Student with Diabetes Succeed 105
10 Diabetes Medical Management Plan (DMMP) page 8 DISASTER PLAN T prepare fr an unplanned disaster r emergency (72 HOURS), btain emergency supply kit frm parent/guardian. Cntinue t fllw rders cntained in this DMMP. Additinal insulin rders as fllws: Other: SIGNATURES This Diabetes Medical Management Plan has been apprved by: Student s Physician/Health Care Prvider Date I, (parent/guardian:) give permissin t the schl nurse r anther qualified health care prfessinal r trained diabetes persnnel f (schl:) t perfrm and carry ut the diabetes care tasks as utlined in (student:) s Diabetes Medical Management Plan. I als cnsent t the release f the infrmatin cntained in this Diabetes Medical Management Plan t all schl staff members and ther adults wh have respnsibility fr my child and wh may need t knw this infrmatin t maintain my child s health and safety. I als give permissin t the schl nurse r anther qualified health care prfessinal t cntact my child s physician/health care prvider. Acknwledged and received by: Student s Parent/Guardian Date Student s Parent/Guardian Date Schl Nurse/Other Qualified Health Care Persnnel Date 106
Diabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff
More informationDiabetes Medical Management Plan (DMMP) Handout C.1
This plan should be completed by the child s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant program staff and copies should be kept in a place that
More informationHomeroom Teacher: Mother/Guardian: Address: Telephone: Home Work. Address: Father/Guardian: Address: Telephone: Home Work Cell: Address:
Community Unit School District No. 1 Diabetes Care Plan 6:120-AP4, E1 This plan should be completed by the student s personal diabetes health care team, including the parents/guardian. It should be reviewed
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the student s personal diabetes health care team, including the parents/guardians. It should be reviewed with relevant school staff
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) Page 1 of 7, DMMP This plan should be completed by the student s personal diabetes health care team, including the parents/guardians. It should be reviewed with
More informationAuthorization for MAT Diabetes Certified Staff to Administer Insulin and/or Glucagon
Medication Administration Training for Child Day Programs Handout B.1 Authorization for MAT Diabetes Certified Staff to Administer Insulin and/or Glucagon Child s Name: Child s Date of Birth: Child Day
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) This plan should be completed by the camper s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant staff and copies
More informationDiabetes Medica Management Pnan (DMMP)
Diabetes Medica Management Pnan (DMMP) This plan should be completed by the student's personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff
More informationDiabetes Medical Management Plan (DMMP) Adapted from Helping the Student with Diabetes Succeed: A Guide for School Personnel (2016)
Diabetes Medical Management Plan (DMMP) Adapted from Helping the Student with Diabetes Succeed: A Guide for School Personnel (2016) This plan should be completed by the student's personal diabetes health
More informationINDIVIDUALIZED HEALTHCARE PLAN DIABETES WITH INJECTION HEALTHCARE PROVIDER ORDERS
INDIVIDUALIZED HEALTHCARE PLAN DIABETES WITH INJECTION HEALTHCARE PROVIDER ORDERS EFFECTIVE DATE: STUDENT S NAME: DIABETES HEALTHCARE PROVIDER INFORMATION Phne #: Fax #: SCHOOL: STUDENTS WITH DIABETES
More informationVirginia Diabetes Medical Management Plan (DMMP)
Virginia Diabetes Medical Management Plan (DMMP) Adapted from the National Diabetes Education Program DMMP (2016) This plan should be completed by the student s personal diabetes health care team, including
More informationDate of birth: Type 2 Other: Parent/guardian 1: Address: Telephone: Home: Work: Cell: address: Camper physician / health care provider:
Day & Evening Camp 2018 Specialized Health Care Diabetes Medical Management Plan Must be completed if your camper has diabetes. Parent/guardian and physician signature required. **We will also accept copies
More informationDiabetes Medical Management Plan (DMMP)
Diabetes Medical Management Plan (DMMP) Page 1 of 7, DMMP This plan should be completed by the student s personal diabetes health care team, including the parents/guardians. It should be reviewed with
More informationTO BE COMPLETED BY LICENSED HEALTH CARE PROFESSIONAL
PART I OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN Student School Date of Birth Date of Diagnosis Grade/ Teacher Physical
More informationUniversity College Hospital. Pump school Starting on an insulin pump. Children and Young People s Diabetes Service
University Cllege Hspital Pump schl Starting n an insulin pump Children and Yung Peple s Diabetes Service 2 If yu wuld like this dcument in anther language r frmat, r require the services f an interpreter,
More informationGetting Started. Learning Guide. with Continuous Glucose Monitoring for the MiniMed 530G with Enlite. CGM Foundations
Getting Started with Cntinuus Glucse Mnitring fr the MiniMed 530G with Enlite Learning Guide CGM Fundatins Cntinuus Glucse Mnitring Learning Guide MiniMed 530G with Enlite - Cntinuus Glucse Mnitring Settings
More informationTO BE COMPLETED BY LICENSED HEALTH CARE PROFESSIONAL
PART I OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN Student School Date of Birth Date of Diagnosis Grade/ Teacher Physical
More informationDiabetes Medical Management Plan
Date of Plan: Diabetes Medical Management Plan Effective Dates: This plan should be completed by the student's personal health care team and parents/guardian. It should be reviewed with relevant school
More informationDiabetes Medical Management Plan
MADISON CONSOLIDATED SCHOOLS Diabetes Medical Management Plan Date of Plan: Effective Dates : The student s personal health care team and parents/guardian should complete this plan. It should be reviewed
More information1.11 INSULIN INFUSION PUMP MANAGEMENT INPATIENT
WOMEN AND NEWBORN HEALTH SERVICE CLINICAL GUIDELINES SECTION A: GUIDELINES RELEVANT TO OBSTETRICS AND GYNAECOLOGY 1 STANDARD PROTOCOLS 1.11 INSULIN INFUSION PUMP MANAGEMENT - INPATIENT Authrised by: OGCCU
More informationDiabetes Medical Management Plan
Diabetes Medical Management Plan This plan 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
More informationName: DOB: Date: School Year: _ _
DIABETES SCHOOL ORDER FORMS Instructions for completing school diabetes order forms: Parents are asked to complete as much as possible, including the skills assessment. Please do not return blank forms
More information9-A. Diabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan This plan 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
More informationLander County School District
Lander County School District of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant
More informationIndividual Health Care Plan-Diabetes
Individual Health Care Plan-Diabetes Effective Date: School Year: 20 to 20 This plan should be completed by the student s diabetes care aide/health clerk and parents/guardians. It should be reviewed with
More informationDiabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan These orders remain in effect during the school day, school sponsored activities, and school sponsored overnight trips. This plan should be completed by the student
More informationDIABETES MEDICAL MANAGEMENT PLAN (DMMP) School Year: Student s Name: Date of Birth:
DIABETES MEDICAL MANAGEMENT PLAN (DMMP) School Year: Student s Name: Date of Birth: BLOOD GLUCOSE (BG) MONITORING: (Treat BG below 80mg/dl or above 150 mg/dl as outlined below.) Before meals as needed
More informationRancocas Valley Regional High School Diabetes Medical Management Plan
of Plan: Rancocas Valley Regional High School Diabetes Medical Management Plan Individualized Healthcare Plan/ 504 Plan will be completed by the school nurse in consultation with the student s parent /guardian
More informationDiabetes Medical Management Plan
of Plan: School year: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff and
More informationVICTORIA INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan
VICTORIA INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. Student s Name: of Birth: of Diabetes
More informationROBINSON INDEPENDENT SCHOOL DISTRICT 500 West Lyndale * Robinson, Texas (254) Fax (254)
ROBINSON INDEPENDENT SCHOOL DISTRICT 500 West Lyndale * Robinson, Texas 76706 (254) 662-0194 Fax (254) 662-0215 To the parents /guardian of : Your child has been identified as having diabetes. Robinson
More informationDate of Diabetes diagnosis Type I Type II. School Nurse Phone. Mother/Guardian. Address. Home phone Work Cell. Father/Guardian.
Diabetes Medical Management Plan/Individualized Healthcare Plan This plan should be completed by the student s physician, personal diabetes healthcare team and parent/guardians. It should be reviewed with
More informationDiabetes Medical Management Plan
Date of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies
More informationPercutaneous Nephrolithotomy (PCNL)
Percutaneus Nephrlithtmy (PCNL) What is a percutaneus nephrlithtmy? is the mst effective f the cmmnly perfrmed prcedures fr kidney stnes. It is the best prcedure fr large and cmplex stnes. T perfrm this
More informationDiabetes Medical Management Plan
SCHOOL DISTRICT OF LEE COUNTY HEALTH SERVICES Print Form Date of Plan Diabetes Medical Management Plan This plan should be completed by the student's personal health care team and parents/guardian. It
More informationDiabetes Medical Management Plan/Individualized Healthcare Plan. Part A: Contact Information must be completed by the parent/guardian.
Middle School 908 689 0750 ext. 2020 WARREN HILLS REGIONAL SCHOOL DISTRICT Washington, NJ 07882 HEALTH OFFICES High School 908 689 3050 ext. 2 MS FAX 908 835 0570 HS FAX 908 835 8511 Diabetes Medical Management
More informationMONMOUTH COUNTY VOCATIONAL SCHOOLS
Diabetes Medical Management Plan/Individualized Healthcare Plan Part A: Contact Information must be completed by the parent/guardian. Part B: Diabetes Medical Management Plan (DMMP) must be completed by
More informationFREEHOLD REGIONAL HIGH SCHOOL DISTRICT. Parents/Guardian of
FREEHOLD REGIONAL HIGH SCHOOL DISTRICT Parents/Guardian of In order to comply with N.J.S.A. 18A:40-12.11-21, which addresses the care of the diabetic student in the school setting, the attached packet
More informationLEON COUNTY SCHOOLS DIABETES MEDICAL MANAGEMENT PLAN & NURSING CARE PLAN (School Year - ) Plan Effective Date(s):
Student s Name: LEON COUNTY SCHOOLS DIABETES MEDICAL MANAGEMENT PLAN & NURSING CARE PLAN (School Year -) Plan Effective Date(s): Date of Diabetes Diagnosis: Type 1 Type 2 School Name: Date of Birth: School
More informationDiabetes Medical Management Plan
of Plan: Diabetes Medical Management Plan (Adapted for JHU/CTY Summer Programs) This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed with
More informationDiabetes Medical Management Plan
Scotus Central Catholic High School 1554 18th Ave., Columbus, NE, 68601; 402-564-7165; FAX 402-564-6004; www.scotuscc.org Diabetes Medical Management Plan Date of Plan: Effective Dates: Student Name: Date
More informationWarren Township School District Diabetes IHCP
Warren Township School District Diabetes IHCP of Plan: Diabetes Health Management Plan This plan should be completed by the student s personal health care team and parents/guardian. It should be reviewed
More informationSCHOOL HEALTH PLAN: DIABETES
BRANDON FLORENCE MCLAURIN NORTHWEST PELAHATCHIE RANKIN COUNTY SCHOOL DISTRICT GREAT TO BEST PISGAH PUCKETT RICHLAND RANKIN COUNTY SCHOOL DISTRICT SCHOOL HEALTH PLAN: DIABETES of Plan: Effective s: This
More informationChild s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT
Date f Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Prtable Medical Summary Name: Date Updated: / / Address: Phne: Mbile: E-mail: DOB: SSN: - - Allergies: Pertinent Persnal Characteristics: What
More informationSCHOOL DISTRICT 308 RETURN TO LEARN (RTL) and RETURN TO PLAY (RTP) PROTOCOL FOR CONCUSSION
SCHOOL DISTRICT 308 RETURN TO LEARN (RTL) and RETURN TO PLAY (RTP) PROTOCOL FOR CONCUSSION **The fllwing is required by the State f Illinis as per Public Act 99-0245** OVERSIGHT CONCUSSION MANAGEMENT TEAM
More informationDIABETES MEDICAL MANAGEMENT PLAN (DMMP)
ESUBMIT Reset Form Print Form DIABETES MEDICAL MANAGEMENT PLAN (DMMP Date of Plan: This plan is valid for the current school year: 20 20 STUDENT INFORMATION Name DOB Type of Diabetes Insulin Program Type
More informationRate Lock Policy. Contents
Rate Lck Plicy Cntents Rate Lcks... 2 Rate Lck Cnfirmatin... 2 Lck Term... 2 Pre-Lck... 2 Maximum Qualified Rate... 3 Extensins... 3 Cst t Extend... 3 Relcks... 4 Re-Negtiatin r Flat Dwn Plicy... 4 Prgram
More informationAnnex III. Amendments to relevant sections of the Product Information
Changes t the Prduct infrmatin as apprved by the CHMP n 13 Octber 2016, pending endrsement by the Eurpean Cmmissin Annex III Amendments t relevant sectins f the Prduct Infrmatin Nte: These amendments t
More informationPain relief after surgery
Pain relief after surgery Imprtant infrmatin fr patients www.mchft.nhs.uk We care because yu matter This leaflet is designed t help yu cntrl any pain yu may have at hme fllwing yur peratin. Please read
More informationDIABETES POLICY Policy Statement & Commitments
Plicy Statement & Cmmitments Willaura Primary Schl Outside Schl Hurs Care Service 1 DIABETES POLICY 2018 Children with Diabetes are n mre likely t be sick than ther yung peple and can generally be expected
More informationPatient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn
More informationInternational School Bangkok Diabetes Management Plan 2018/19
International School Bangkok Diabetes Management Plan 2018/19 Student Family Name: Given Names: Date of Birth (dd/mm/yyyy): Grade at ISB (2018/19): Date of Plan (dd/mm/yyyy): Mother s Name: Phone: Father
More informationMethadone Maintenance Treatment for Opioid Dependence
POLICY STATEMENT Methadne Maintenance Treatment fr Opiid Dependence APPROVED BY COUNCIL: May 2010 PUBLICATION DATE: Dialgue, Issue 2, 2010 Disclaimer: As f May 19, 2018 physicians n lnger require an exemptin
More informationEMERGENCY CARE PLAN FOR DIABETES West Fargo Public School. Student Date Grade DOB Parent/Guardian Phone (H) BLOOD SUGAR TESTING
EMERGENCY CARE PLAN FOR DIABETES West Fargo Public School Student Date Grade DOB Parent/Guardian Phone (H) (C) (W) Does this student ride the bus: Yes No Preferred Hospital In Case of Emergency Physician
More informationAPPENDIX #1: SAMPLE Diabetes Medical Management Plan (DMMP)
APPENDIX #1: SAMPLE Diabetes Medical Management Plan (DMMP) Date of Plan: Diabetes Medical Management Plan This plan should be completed by the student s personal health care team and parents/guardian.
More informationHuon Logistics Isolation & Lockout Work Instruction 1. LOCKOUT DEVICES 2. LIGHT VEHICLE POSITIVE ISOLATION POINTS - 1 -
Hun Lgistics Islatin & Lckut Wrk Instructin Prcedure 1. LOCKOUT DEVICES Explanatin When an islatin f any mbile plant r equipment is required befre safe access t a machine can be prvided the fllwing must
More informationDIABETES MEDICAL MANAGEMENT PLAN
Revised 10/2017 DIABETES MEDICAL MANAGEMENT PLAN The student s healthcare provider and parents/guardians should complete this form. Please fill out entire form. Review with relevant school personnel who
More informationGUIDANCE DOCUMENT FOR ENROLLING SUBJECTS WHO DO NOT SPEAK ENGLISH
GUIDANCE DOCUMENT FOR ENROLLING SUBJECTS WHO DO NOT SPEAK ENGLISH Aurra Health Care s Research Subject Prtectin Prgram (RSPP) This guidance dcument will utline the prper prcedures fr btaining and dcumenting
More informationNIA Magellan 1 Spine Care Program Interventional Pain Management Frequently Asked Questions (FAQs) For Medicare Advantage HMO and PPO
NIA Magellan 1 Spine Care Prgram Interventinal Pain Management Frequently Asked Questins (FAQs) Fr Medicare Advantage HMO and PPO Questin GENERAL Why is Flrida Blue implementing a Spine Management prgram
More informationIdaho Naturopathic Medicine 6550 W Emerald, Ste 112 Boise, Idaho Ph: Fax:
Idah Naturpathic Medicine 6550 W Emerald, Ste 112 Bise, Idah 83704 Ph: 208-275- 0007 Fax: 208-323-9909 www.idahnaturpathicmedicine.cm Welcme t Idah Naturpathic Medicine We lk frward t meeting yu sn. It
More informationCSHCN Services Program Benefits to Change for Outpatient Behavioral Health Services Information posted November 10, 2009
CSHCN Services Prgram Benefits t Change fr Outpatient Behaviral Health Services Infrmatin psted Nvember 10, 2009 Effective fr dates f service n r after January 1, 2010, benefit criteria fr utpatient behaviral
More informationColonoscopy MoviPrep Split-dose Prep Guide
Yu have been scheduled fr a Clnscpy MviPrep Split-dse Prep. Plan ahead t help reduce yur stress. Use these step-by-step instructins fr a successful prep s that yur dctr can clearly view yur cln. If yu
More informationEAST VALLEY DERMATOLOGY CENTER
EAST VALLEY DERMATOLOGY CENTER Adult and Pediatric Dermatlgy VALLEY SKIN CANCER SURGERY PATIENT INFORMATION RECORD Please Use Black Ink Only Patient Infrmatin Patient s Name Last First Middle Initial Address
More informationThe Impact of Exercise on Blood Glucose. Jacqueline Shahar, MEd, RCEP, CDE Clinical Exercise Physiologist CerCfied Diabetes Educator
The Impact f Exercise n Bld Glucse Jacqueline Shahar, MEd, RCEP, CDE Clinical Exercise Physilgist CerCfied Diabetes Educatr In this sessin yu will learn Trends in glucse prduccn and uclizacn with exercise
More informationPROCEDURAL SAFEGUARDS NOTICE PARENTAL RIGHTS FOR PRIVATE SCHOOL SPECIAL EDUCATION STUDENTS
PROCEDURAL SAFEGUARDS NOTICE PARENTAL RIGHTS FOR PRIVATE SCHOOL SPECIAL EDUCATION STUDENTS INTRODUCTION This ntice prvides an verview f the parental special educatin rights, smetimes called prcedural safeguards
More informationBenefits for Anesthesia Services for the CSHCN Services Program to Change Effective for dates of service on or after July 1, 2008, benefit criteria
Benefits fr Anesthesia Services fr the CSHCN Services Prgram t Change Effective fr dates f service n r after July 1, 2008, benefit criteria fr anesthesia will change fr the Children with Special Health
More informationLower Extremity Amputation (LEA) Considerations / Issues
Lwer Extremity Amputatin (LEA) Cnsideratins / Issues Prviding Te Fillers can be an advantageus resurce fr yur patient and business but it als cmes with certain cnsideratins. Please review this list belw
More informationACRIN 6666 Screening Breast US Follow-up Assessment Form
Screening Breast US Fllw-up Assessment Frm N. Instructins: The frm is cmpleted at 12, 24 and 36 mnths pst initial n study mammgraphy and ultrasund by the Radilgist r RA. Reprt all interim infrmatin related
More informationNational Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For PA Health & Wellness Providers
Natinal Imaging Assciates, Inc. (NIA) Frequently Asked Questins (FAQ s) Fr PA Health & Wellness Prviders Questin GENERAL Why is PA Health & Wellness implementing a Medical Specialty Slutins Prgram? Answer
More informationAdvantage EAP Employee Assistance Program
Advantage EAP Emplyee Assistance Prgram July 2014 In This Issue What might we face? Symptms f SAD Seasnal changes in biplar disrder Tips fr cmbating summer truble When t seek help Tips fr helping thse
More informationUpper Endoscopy (EGD) Prep Guide
Upper Endscpy (EGD) Prep Guide Yu have been scheduled fr an Upper Endscpy (EGD). Plan ahead t help reduce yur stress. Use these step-by-step instructins fr a successful prcedure s that yur dctr can clearly
More information3903 Fair Ridge Drive, Suite 209, Fairfax, VA Harry Byrd Hwy, Suite 285, Ashburn, VA *How did you hear about our program?
3903 Fair Ridge Drive, Suite 209, Fairfax, VA 22033 44121 Harry Byrd Hwy, Suite 285, Ashburn, VA 220147 *Hw did yu hear abut ur prgram? Patient Histry Patient Name: First Middle: Last: Address: City: State:
More informationColonoscopy Colyte Split-dose Prep Guide
Clnscpy Clyte Split-dse Prep Guide Yu have been scheduled fr a Clnscpy Clyte Split-dse Prep. Plan ahead t help reduce yur stress. Use these step-by-step instructins fr a successful prep s that yur dctr
More informationIntravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
Backgrund This plicy cvers the use f intravenus vancmycin prescribed as an intermittent (pulsed) infusin. This can be used fr treatment r prphylaxis. Evidence supprting this guidance is detailed belw.
More informationCompleting the NPA online Patient Safety Incident Report form: 2016
Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 The infrmatin cntained within this dcument is in line with the current Data Prtectin Act (DPA) requirements. This infrmatin may be subject
More informationDear Parents/Guardians:
CEDAR MOUNTAIN PRIMARY SCHOOL P.O. Box 420/17 Sammis Road, Vernon, NJ 07462 Phone: 973-764-2890 Fax: 973-764-3294 Web: www.vtsd.com Dear Parents/Guardians: Rosemary Gebhardt, Principal rgebhardt@vtsd.com
More informationFee Schedule - Home Health Care- 2015
Fee Schedule - Hme Health Care- 2015 01/01/2015 1600 E Century Ave Ste 1 PO Bx 5585 Bismarck ND 58506-5585 www.wrkfrcesafety.cm Cpyright Ntice The five character cdes included in the Nrth Dakta Fee Schedule
More informationInstructions and Helpful Information for D-5 Form. Preliminary Approval of Dissertation and Request for Oral Defense (D-5)
Instructins and Helpful Infrmatin fr D-5 Frm Preliminary Apprval f Dissertatin and Request fr Oral Defense (D-5) 1. DEADLINES D-5 must be submitted t the UGS at least 3 WEEKS BEFORE the date f the defense
More informationThe clinical trial information provided in this public disclosure synopsis is supplied for informational purposes only.
The clinical trial infrmatin prvided in this public disclsure synpsis is supplied fr infrmatinal purpses nly. Please nte that the results reprted in any single trial may nt reflect the verall ptential
More informationNational Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQs) For Louisiana Healthcare Connections Providers
Natinal Imaging Assciates, Inc. (NIA) Frequently Asked Questins (FAQs) Fr Luisiana Healthcare Cnnectins Prviders Questin GENERAL Why did Luisiana Healthcare Cnnectins implement a Medical Prgram? Answer
More informationQP Energy Services LLC Hearing Conservation Program HSE Manual Section 7 Effective Date: 5/30/15 Revision #:
QP Energy Services LLC Hearing Cnservatin Prgram HSE Manual Sectin 7 Effective Date: 5/30/15 Revisin #: Prepared by: James Aregd Date: 5/30/15 Apprved by: James Aregd Date: 5/30/15 Page 1 f 8 Cntents Sectin
More informationNational Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQs) For Managed Health Services (MHS)
Questin GENERAL Why did MHS implement a Medical Specialty Slutins Prgram? Natinal Imaging Assciates, Inc. (NIA) Frequently Asked Questins (FAQs) Fr Managed Health Services (MHS) Answer Effective Nvember
More informationParent Form DIABETES MEDICAL MANAGEMENT PLAN This form must be renewed each school year or with any change in treatment plan
Parent Form Student s PARENT CONSENT FOR We (I), the undersigned, the parent(s)/guardian(s) of the above named child, request that this Diabetes Medical Management Plan, and any modification thereto, be
More informationBariatric Surgery FAQs for Employees in the GRMC Group Health Plan
Bariatric Surgery FAQs fr Emplyees in the GRMC Grup Health Plan Gergia Regents Medical Center and Gergia Regents Medical Assciates emplyees and eligible dependents wh are in the GRMC Grup Health Plan (Select
More informationIntravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
Intravenus Vancmycin Use in Adults Intermittent (Pulsed) Infusin Backgrund This plicy cvers the use f intravenus vancmycin prescribed as an intermittent (pulsed) infusin. This can be used fr treatment
More informationGuidelines for the Care Needed for Students with Diabetes
Guidelines for the Care Needed for Students with Diabetes for the implementation of State Board of Education Rule 160-4-8-.18 Diabetes Medical Management Plans Version 1.2 Table of Contents (1) DEFINITIONS:...
More informationDiabetes Medical Management Plan
Diabetes Medical Management Plan 1 School District: School: School Year: Grade: Student Name: DOB: Provider Name: Phone #: Fax #: Blood Glucose Monitoring at School Blood Glucose Target Range: - mg/dl
More informationPROVIDER ALERT. Comprehensive Diagnostic Evaluation (CDE) Guidelines to Access the Applied Behavior Analysis (ABA) Benefit.
Cmprehensive Diagnstic Evaluatin (CDE) Guidelines t Access the Applied Behavir Analysis (ABA) Benefit May 5, 2017 Clinical infrmatin that utlines medical necessity is required t supprt the need fr initial
More informationList the health concerns that brought you into this office
New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Email Address Occupatin Emplyer s Name Single / Married / Divrced / Widwed
More informationHealth Screening Record: Entry Level Due: August 1st MWF 150 Entry Year
Health Screening Recrd: Entry Level MIDWIFERY EDUCATION PROGRAM HEALTH SCREENING REQUIREMENTS (Rev. June 2017) 1. Hepatitis B: Primary vaccinatin series (3 vaccines 0, 1 and 6 mnths apart), plus serlgic
More informationRecord of Revisions to Patient Tracking Spreadsheet Template
Recrd f Revisins t Patient Tracking Spreadsheet Template Belw is a recrd f revisins made by the AIMS Center t the Patient Tracking Spreadsheet Template. The purpse f this dcument is t infrm spreadsheet
More informationMEDICATION GUIDE. (canagliflozin) Tablets
MEDICATION GUIDE INVOKANA (in-v-kahn-uh) (canagliflzin) Tablets What is the mst imprtant infrmatin I shuld knw abut INVOKANA? INVOKANA can cause imprtant side effects, including: Dehydratin. INVOKANA can
More informationDear Student, IMMUNIZATION RECORD INSTRUCTIONS
Dear Student, Welcme t the University f Chicag! The State f Illinis and University regulatins require students t prvide prf f required immunizatins prir t registratin fr classes. In rder t cmplete this
More informationInformationNOW Attendance
InfrmatinNOW Attendance Abut this Guide This Quick Reference Guide prvides an verview f the setup, entry and reprting f attendance in InfrmatinNOW. Users are advised t refer the apprpriate InfrmatinNOW
More informationDo you have any of the symptoms listed below? Please circle all that apply.
D yu have any f the symptms listed belw? Please circle all that apply. Parkinsn s Symptms: Truble walking Falls Feet sticking t the flr Tremr Medicatins wearing ff Truble sleeping Vivid dreams Thrashing
More information/0515 Medication Guide Aripiprazole Tablets
8415721/0515 Medicatin Guide Aripiprazle Tablets (air-eh-pip-rah-zle) Read this Medicatin Guide befre yu start taking aripiprazle tablets and each time yu get a refill. There may be new infrmatin. This
More informationTwo Day Colonoscopy Preparation PEG (GoLYTELY) & Dulcolax Prep
Tw Day Clnscpy Preparatin PEG (GLYTELY) & Dulclax Prep Thank yu fr chsing t have yur clnscpy with NSPG Gastrenterlgy. We are delighted t be able t participate in yur healthcare and we will make every attempt
More information