Authorization for Use and/or Disclosure Of Protected Health Information to Schools

Transcription

1 PATIENT INFORMATION (Please Print): Authorization for Use and/or Disclosure Of Protected Health Information to Schools MEDICAL RECORD #: Last Name First Name Middle Initial Maiden Name (if applicable) Gender Address City State Zip Code Phone Number Date of Birth Social Security Number Address (optional) Please check/specify the following type of information, including dates of treatment, that you want to be disclosed pursuant to this Authorization. Failure to specify will render this Authorization invalid. Dates of Treatment/Particular Illness/Admission Requested: Discharge Summary History & Physical Educational Evaluations Speech and Language Evaluations Occupational Therapy/Physical Therapy Evaluations Hospital School Attendance School Recommendations Academic/Educational Information Other Other Other ALL INPATIENT MEDICAL RECORDS (See Note) ALL OUTPATIENT MEDICAL RECORDS (See Note) Purpose for Disclosure School The purpose of the use and/or disclosure of this information is to best provide for the student s educational, physical and emotional adjustment between the hospital setting and the school setting. Disclose Records To: Name School Title Street Address City, State, Zip Telephone Number Records may be: Mailed Picked up by Whom: Reviewed only In-Person Meeting Faxed Shared by Telephone This Authorization will expire 60 days after the date below, or sooner by my choice, in which case, Authorization will expire on, or (event) occurs. This Authorization may be revoked at any time to the extent that use and/or disclosure has not already occurred prior to your request for revocation. In order to revoke the Authorization the individual/parent/legal guardian must submit a revocation request in writing to the Health Information Management department, Please refer to Cincinnati Children's Hospital Medical Center's (CCHMC) Notice of Privacy Practices. CCHMC will not condition treatment, payment, enrollment or eligibility for benefits on the execution of this Authorization. The information used or disclosed as a result of this Authorization may be subject to redisclosure by the person or entity receiving such information, and thus no longer protected by the federal privacy regulations. I understand that a standardized fee has been established for copies of medical records. Please inquire regarding these fees prior to requesting copies. I, the undersigned, hereby authorize Cincinnati Children s Hospital Medical Center to use and/or disclose information from my (or give relationship) medical or financial record as specified above. This authorization includes the use and/or disclosure of information concerning HIV testing or treatment of AIDS or AIDS-related conditions, any drug or alcohol abuse, drug-related conditions, alcoholism, and/or psychiatric/psychological conditions to the above mentioned entity(s). Signature: Date: Patient Parent Legal Guardian The above statements must be signed and dated to be valid. If the patient is an emancipated minor or 18 years of age, he/she is required to sign the Authorization. If CCHMC requests this Authorization for its own use or disclosure, a copy of this Authorization must be provided to the individual completing this form. Request Has Been Fulfilled: Yes, Initials Date Cincinnati Children s Hospital Medical Center 3333 Burnet Avenue MLC-5015 Cincinnati, Ohio Form F01b CCHMC HIPAA Privacy Policy I-305, Authorization for Use or Disclosure of PHI Effective 4/14/03

2 April 23, 2012 Dear Parent / Guardian: We have attached a copy of our Diabetes School Orders and packet for the school year. Each year you will receive an updated copy of the school orders for the upcoming school year at your clinic visit in the spring or summer. We ask that you take time to review the packet at home, and schedule a meeting with school staff to review the packet before the next school year. First, please complete a Release of Health Information to Schools form and leave it with the front desk staff. This release will allow your child s school to contact the Diabetes Center for issues or any questions they may have about your child s diabetes care. Review Returning to School with Diabetes: Parent Guide that includes a list of diabetes supply needs and provides safe care for your child during the school year. Review the School Orders and complete the parent s section on the last page. Each year it is important to review the School Orders with your child s school personnel. Complete an Individual Diabetes Management Plan found in your child s school packet with appropriate school personnel. This provides you with the chance to develop a more individualized plan for directing your child s diabetes care at school. All forms except the physician signed school orders may be found on the Cincinnati Children s Diabetes Center website at If you have any questions about the school packet, please feel free to ask to speak with a social worker in the Diabetes Center at Sincerely, Diabetes Center Healthcare Team

3 RETURNING TO SCHOOL WITH DIABETES PARENT GUIDE It can be stressful returning to school regardless of whether you have been living with diabetes for years or were just diagnosed yesterday. Here are suggestions in preparing for your return. 1. Each year before returning to school or upon diagnosis, call as soon as possible to schedule a meeting with the school personnel. It will be helpful if you can include any or all of the following applicable personnel: School Nurse (If you do not have a school nurse ask the school who will be helping with your child s diabetes and include them in the meeting i.e. secretary) Nurse s Aide/Administrative Support Staff Teacher Principal Food Service Manager Bus Driver Counselor Physical Education Teacher/Coach 2. Bring your school packet including School Orders to the meeting. Contact your Diabetes Center Social Worker if you have questions about these forms at (513) Remember to complete MUST BE COMPLETED BY PARENT section on School Orders. 3. Diabetes supplies/equipment to be kept at school based on insulin therapy: Basal/Bolus Insulin Therapy/ Insulin Pump Therapy Supplies Blood Glucose Meter Test Strips Lancet Device Lancets Ketone Test Strips Glucagon Emergency Kit Insulin Pen Pen Needles Syringes Insulin Extra Pump Supplies (insulin pump users) Supply of snacks/items to treat low blood glucose Split/Mixed Insulin Therapy Supplies Blood Glucose Meter Test Strips Lancet Device Lancets Ketone Test Strips Glucagon Emergency Kit Insulin (based on individual needs) Syringes Supply of snacks/items to treat low blood glucose Questions you may want to ask: Who will help my child with blood glucose monitoring? or (backup) Who will assist and/or give my child insulin at school if needed? Who will call me when my child s diabetes supplies need replaced? Who will remind my child to eat his/her snack (if applicable)? Arrange with school personnel location of supplies and designated areas for testing of blood glucose. Arrange a plan for school personnel to report blood glucose results to parents. Designate an area to store items used to treat low blood glucose. Recurrent absences or requests to be excused from class due to diabetes should be carefully evaluated. 3/8/2012

4 School Orders for a Student with Diabetes on Insulin Pump Therapy for School Year Student Name: Address: Date of Birth: School Name: Grade: Blood Glucose (BG) Testing Test the BG prior to eating meals and snacks that contain carbohydrates. Test the BG if the student has signs/symptoms of a high or low BG. Test the BG if the child is ill. Additional tests may be needed related to physical activity, bus rides and test taking; Refer to individualized health plan to be completed by the school and parent. Urine Ketone Testing Test the urine for ketones if the child is ill. Test the urine for ketones if the BG is greater that 240 mg/dl. Follow the instructions on the test strip container that specifies the timing of the test and how to interpret the results. Check expiration date on the container. If student is measuring blood ketones using the Precision Xtra TM meter, follow the above guidelines when to test and the instructions for performing blood ketones testing and reading results. Insulin Administration Store unopened vial of insulin in the refrigerator (36-46 F). After the vial is opened, it may be kept at room temperature and should be discarded after 4 weeks. Keep several syringes at school in case injection is needed. Administer rapid-acting insulin lispro (Humalog ), aspart (Novolog ), or glulisine (Apidra ) by an insulin pump within 15 minutes before eating. If the child is an unpredictable eater, the insulin may be given after eating (with a 30 minute limit for eating) per request of the parent. Administer rapid-acting insulin lispro (Humalog ), aspart (Novolog ), or glulisine (Apidra ) by injection if a pump or infusion set malfunction is suspected, as evidenced by a high BG and positive urine ketones (see Management of High BG, page 2). Parent(s) are responsible for communicating the correct dose of insulin and any change in the dose of insulin. The insulin dose is determined by calculating the carbohydrate (carb) bolus and the correction bolus prior to eating: To calculate a carb bolus: 1. Add up the total grams of carbs to be eaten. 2. Divide the total number of grams of carbs by the carb ratio EXAMPLE Total carbs are 87 grams. The carb ratio is 1 unit per 12 grams of carbs = 7.3 units of insulin To calculate correction bolus for BG above target**: 1. Subtract the target BG from the current BG 2. Divide by the correction factor EXAMPLE Current BG is 257 mg/dl. Target BG is 140 mg/dl. Correction factor is 1 unit of insulin for every 50 mg/dl above target BG = = 2.3 units of insulin To calculate total bolus dose of insulin to be given: 1. Add carb bolus and correction bolus (if applicable) EXAMPLE 7.3 units (carb bolus) units (correction bolus) = 9.6 total units Note: **DO NOT give correction bolus if less than three hours since last bolus insulin dose OR less than one hour since vigorous exercise OR if low BG occurred in previous three hours. Page 1 of 3 2/16/2012

5 Insulin Pump Orders for School Year Management of High Blood Glucose (Hyperglycemia) High BG with Negative to Trace Ketones Urine Ketones (or Blood Ketones less than 0.6 mmol/l): o A correction bolus is needed if the BG is above the target BG and it has been at least three hours since the last dose of rapid-acting insulin. The parent may elect to use the active insulin or insulin on board feature to calculate a reduced correction sooner than the standard three hour interval. o Use caution during physical activity, if the BG is greater than 300 mg/dl and urine ketones are negative or trace (or blood ketones are less than 0.6 mmol/l). Recheck blood glucose and ketones in 30 minutes. o The child should be encouraged to drink water or carb-free/caffeine-free liquids. o Monitor the BG and urine ketones at least every three hours. High BG with Small, Moderate, or Large Urine Ketones (or Blood Ketones greater than 0.6 mmol/l): o Parents should be notified immediately; if unable to reach the parent(s), contact the Diabetes Center, (513) Additional insulin for ketones may be needed; give as directed by the parent or a Diabetes Center provider. o Give all corrections by injection until the BG is less than 240 mg/dl and ketones are less than moderate and the infusion set and reservoir have been changed. The infusion set and reservoir must be changed as soon as possible. o A correction is needed if the BG is above the target BG and it has been at least three hours since the last dose of rapid-acting insulin. This correction must be given by injection. o The child should refrain from physical activity until the ketones are negative. o The child should be encouraged to drink water or carb-free/caffeine-free liquids. o o Monitor the BG and urine ketones at least every three hours if the child remains at school. Check for ketones until negative and BG is less than 240 mg/dl. Diabetic ketoacidosis (DKA) is a medical emergency. The child will need immediate medical treatment. The signs of DKA are: rapid breathing, rapid heart rate, capillary refill greater than three seconds, altered consciousness, prolonged vomiting and/or abdominal pain Management of Low Blood Glucose (Hypoglycemia) If the BG is less than 70 mg/dl (children 6 years and older) or less than 80 mg/dl (children less than 6 years old) and the child can safely consume food/drink, give 15 grams of fast-acting carbs (4 oz juice or regular pop, 3-4 glucose tablets or 5-8 lifesavers). Some parents may elect to use less than 15 grams of carbs for mild hypoglycemia. Retest BG in 15 minutes. Retreat if necessary with 15 grams of carbs until BG is greater than 70 mg/dl (children 6 years and older) or greater than 80 mg/dl (children less than 6 years old). If unable to test BG, but child is symptomatic of low BG, treat as noted above. Contact the parent(s) if the child required two or more carb treatments in one day for a low BG or if the BG was less than 50 mg/dl. Page 2 of 3 2/16/2012

6 Insulin Pump Orders for School Year Emergency treatment: If the child has symptoms of a low BG and is unable or refuses to eat or drink, is unconscious, or is having a seizure, do the following: o Administer glucagon (Glucagon Emergency Kit): Have trained personnel mix and administer the glucagon. The glucagon is determined by the weight of the child: If child weighs less than 44 lbs (20 kg), give 0.5 mg intramuscularly (IM) If child weighs 44 lbs (20 kg) or more, give 1 mg IM o If child s weight is unknown, give 0.5 mg IM for 5 years of age and younger or 1 mg IM for 6 years of age and older. Turn child on his/her side in case of nausea or vomiting. Call 911. o If glucagon or trained personnel are not available, Call 911. o o Stay with the child until emergency help arrives. Have someone contact parent(s). When the child awakens and can swallow, encourage the child to take small sips of a carbcontaining fluid (fruit juice or regular pop). If tolerated, follow with 15 grams of a carb and fat-containing food (such as peanut butter and crackers). Lawrence Dolan, M.D., Medical Director, Diabetes Center Cincinnati Children s Hospital Diabetes Center Providers: Nathan Bingham, MD, Mandi Cafasso, CNP, Janet Chuang, MD, Sarah Corathers, MD, Nancy Crimmins, MD, Deborah Elder, MD, Marjorie Golekoh, MD, Iris Gutmark Little, MD, Michele Hanson, CNP, Jonathan Howell, MD, Pranati Jha, MD, Christel Keefe, MD, Jennifer Kelly, CNP, David Klein, MD, PhD, Sarah Lawson, MD, Ann Malinowski, CNP, Nancy Morwessel, CNP, Cassandra Neureiter, MD, Chris Osborn, CNP, Erica Reynolds, MD, Susan Rose, MD, Meilan Rutter, MD, Amy Shah, MD, Arti Shah, MD, Nicole Sheanon, MD, Stephanie Sisley, MD, Debbie Standiford, CNP, Peggy Stenger, DO, Amanda Sylvester, CNP, Karishma Tilton, CNP, Nana-Hawa Yayah Jones, MD, Haley Wasserman, MD Parent must complete: Type of insulin: insulin lispro (Humalog ) insulin aspart (Novolog ) insulin glulisine (Apidra ) Carb ratio for food: 1 unit for grams of carbohydrates Correction target BG: mg/dl Correction factor: 1 unit for every mg/dl above correction target Parental signature Date Parent(s) are responsible for communicating the correct dose of insulin and any change in the dose of insulin. Page 3 of 3 2/16/2012

7 Individual Diabetes Management Plan for Student on Insulin Pump Therapy School Year Student Name: Address: Date of Birth: School Name: Grade: Medical condition: Type 1 Diabetes Type 2 Diabetes Primary school person responsible for care: Secondary school person to provide care: Alternate school person(s) trained in Glucagon administration: Additional school persons trained to recognize and respond to low BG (with exception of administering Glucagon): Bus driver Gym teacher Other (Name and Title): Contact Information Mother/Guardian: Telephone: Home Work Cell Father/Guardian: Telephone: Home Work Cell Other Emergency Contact: Name: Relationship: Telephone: Home Work Cell Diabetes Health Care Provider: Name: Diabetes Center, Cincinnati Children s Hospital Medical Center Address: 3333 Burnet Ave., Cincinnati, OH Telephone: (513) Target Range: mg/dl Blood Glucose (BG) Testing Usual times to test BG: Additional times to test BG: Before physical activity After physical activity When student has symptoms of high BG (hyperglycemia) When student has symptoms of low BG (hypoglycemia) Before student boards bus at end of school day Other: Can student perform own blood glucose testing? Yes No Where will testing occur? Classroom Health Room Main Office Other Page 1 of 3 2/16/2012

8 Individual Diabetes Management Plan Insulin Pump How will parent/guardian be notified of BG values obtained at school? Daily phone call Daily written communication Other Insulin Administration Insulin pump: Manufacturer Model Number Type of insulin: insulin lispro (Humalog ) insulin aspart (NovoLog ) insulin glulisine (Apidra ) Is student using insulin on board or active insulin feature? Yes No Insulin Dosages Parents are responsible for communicating the correct dose of and any change in the dose of insulin; this is supported in the school medical orders signed per Dr. Dolan, Medical Director of the Diabetes Center, Cincinnati Children s Hospital Medical Center. Count carbohydrate grams Calculate carb and correction bolus Administer carb and correction bolus Student Abilities/Skills Adult Needs Adult Needs No Assistance to Perform to Assist Needed by Student Suspend/resume insulin delivery Set/cancel temporary basal rate Disconnect/reconnect pump Prepare reservoir and tubing Insert infusion set Troubleshoot alarms and malfunctions Contact Parent No Assistance Needed by Student Food Fast-acting carbohydrates such as are required to treat a low BG or to prevent a low BG (by giving to the student prior to vigorous physical activity). These will be kept. Food service personnel need to be able to provide the serving size of items included on the school menu. Instructions for when food is provided to a class on special occasions (i.e. birthday party, holiday event): Field Trips School personnel designated to provide/supervise diabetes care on field trip(s): Page 2 of 3 2/16/2012

9 Individual Diabetes Management Plan Insulin Pump Physical Activity Guidelines Physical activity usually lowers blood glucose. The drop in blood glucose may be immediate or delayed as much as hours The child will need fast-acting carbohydrates without insulin coverage for every 30 minutes of vigorous physical activity. This amount may need to be adjusted later after seeing the effect on blood glucose. (Refer to Activity Table) Do not give a high blood glucose correction bolus within 1 hour of vigorous or prolonged activity. Activity Table: Type of Activity Low / Light Slower walk During activity can easily talk or sing Moderate Faster walk During activity can talk in short phrases Vigorous/Strenuous Running During activity can have difficulty talking easily Blood Glucose Amount of Fast-Acting Carbs for Every 30 Minutes of Activity mg/dl 5-10 grams mg/dl None mg/dl grams mg/dl 5-10 grams mg/dl None mg/dl grams mg/dl grams mg/dl 5-10 grams Glucagon for Treatment of Severe Low BG The Emergency Glucagon Kit will be kept:. Refer to the separate form and school orders for details regarding use and administration. Blood glucose meter Blood glucose test strips Lancet device Lancets Ketone test strips Supplies to be Kept at School Extra pump supplies Insulin vial or cartridge Insulin syringes or pen needles Glucagon emergency kit Supply of fast-acting carbohydrates School personnel who will notify parent when supplies are getting low: Acknowledged and received by: Student s Parent/Guardian Date School Representative and Title Date Page 3 of 3 2/16/2012

10 Diabetes Care at School I. Introduction It is important for a child with diabetes to take part in school activities for physical, emotional, and social wellbeing. The child s age, length of time since diagnosis, and developmental stage will affect his or her ability to perform various tasks independently. The amount of assistance from the school may vary from child to child. Substitute teachers will also need to be informed of students with diabetes. The Diabetes ID sheet can be used to communicate pertinent information. The diabetes team and the family will determine the frequency of blood glucose (BG) checks while at school based on the child s medical needs. The family will communicate this information to the appropriate school personnel. II. Diabetes Overview A. Definition of Diabetes: When a person has diabetes, their body either cannot make insulin or the insulin that their body makes does not work properly. The body needs insulin to function properly and convert food to energy. In the absence of insulin or if the insulin produced is unable to function properly, a person s blood glucose level will rise above normal values. This is called hyperglycemia (high blood glucose) and is an indication of diabetes. B. Common Signs and Symptoms of Hyperglycemia: Frequent urination Increased thirst Increased hunger Weakness/Fatigue Unexplained weight loss Blurred vision Irritability C. Type 1 Diabetes: Cells in the pancreas that make insulin are destroyed Insulin injections or insulin pump therapy are required Most commonly occurs in children Makes up 10 percent of all cases of diabetes D. Type 2 Diabetes: The insulin that the body makes does not work properly. Treatment may include any or all of the following: insulin injections, pills, diet and exercise Most commonly occurs in adulthood, but the number of children and adolescents developing type 2 diabetes is increasing. Page 1 of 3 Diabetes Care at School 4/7/09

11 Strong family history Makes up 90 percent of all cases of diabetes E. Facts about diabetes: Diabetes is not caused by eating too much sugar. There is nothing you could do to prevent type 1 diabetes. A person cannot catch diabetes from someone else. III. Nutrition and Diabetes A. General Facts: The nutritional needs of a child with diabetes and a child without diabetes are the same. Both diets should include a variety of foods in order to promote proper growth and development. Treatment for diabetes consists of finding a balance between carbohydrate, insulin and exercise to keep blood glucose (BG) levels within a safe range. B. Carbohydrates: Foods that contain carbohydrates increase BG levels. This does not mean that the individual with diabetes should avoid carbohydrates. Instead, he/she needs to learn to count carbohydrate grams to match the insulin. There are many sources to assist with carbohydrate counting such as food labels, the internet, and fast food guides. Examples of foods that contain carbohydrates are: Starches bread, cereal (sweetened and unsweetened), pasta, rice, potatoes, corn, peas, crackers, popcorn Fruits fresh, frozen, canned, and juices Milk milk and yogurt Others cakes, cookies, candy, chips, ice cream The American Diabetes Association and The American Dietetic Association recommend that sweets can be included within the context of a healthy diet. Foods that contain proteins and fats have little or no effect on blood glucose levels. However, if eaten in excess can cause weight gain. IV. Insulin Therapy Options A. Basal/Bolus Injection Insulin Therapy and Insulin Pump Therapy: BG must be checked prior to the administration of insulin and to eating foods with carbohydrates. Insulin dose is based on the grams of carbohydrate to be eaten and the BG reading. (Refer to attached School Orders for calculating insulin dose) Insulin must be given before each meal or snack containing carbohydrates. Page 2 of 3 Diabetes Care at School 4/7/09

12 Parties/Special Events/Field Trips: This insulin regimen allows for flexibility in timing of meals as well as amounts of carbohydrates. Treats can be eaten with other students, but insulin must be given to cover the grams of carbohydrates. Insulin will need to be taken along for field trips. Extra carbohydrate snacks should also be kept with the student in case of hypoglycemia. B. Split/Mixed Insulin Therapy (NPH and Regular Insulin): Two insulin injections generally given by parents at home (i.e., usually at breakfast and supper). 3 meals and 3 snacks at specific times each day (Refer to student s specific meal plan). A specific amount of carbohydrate at each meal and snack. Checking BG before meals (while at school: before lunch) or if the student exhibits signs of low blood glucose or illness. (Refer to attached Hypoglycemia Emergency Plan for a Student with Diabetes) Parties/Special Events/Field Trips: Meal/snack timing should be about the same time each day for optimal blood glucose control. Altering meal/snack times can result in high or low blood glucose levels. If possible, notify the student s family ahead of time to include them in the plans. Parties are often scheduled 1½ -2 hours after lunch, which usually matches closely with the student s regular snack time. Parties generally include carbohydrates (cake, cookies, chips, ice cream, etc.). The treat or a portion of the treat may fit into the student s meal/snack plan. Students should be allowed to eat on the bus/van if necessary. V. Exercise/Activity/Gym Class Children with diabetes can participate in all activities. Exercise and activity, such as recess, may lower BG levels. To maintain safe BG levels for activity/exercise, the student may need to take extra grams of carbohydrates before a physical activity (Refer to attached Physical Activity and Diabetes Guidelines table in Management Plan). Be aware of the signs and symptoms of low BG (Refer to attached Hypoglycemia Emergency Plan for a Student with Diabetes). ALWAYS have a fast acting carbohydrate (i.e. juice) in case of low BG. The P.E. instructor/recess supervisor will need to be aware of the student with diabetes as well as know the signs and treatment of low BG. The instructor should take into consideration the time and duration of the activity. Students with gym/recess before lunch are at greater risk for low BG due to the length of time since they last ate. Page 3 of 3 Diabetes Care at School 4/7/09

13 Hyperglycemia (High Blood Glucose) Treatment For a Student with Diabetes Student s Name Grade Teacher Date Emergency Contact Information: Mother/Guardian Home Phone Work Phone Cell Phone Father/Guardian Home Phone Work Phone Cell Phone Causes of Hyperglycemia Not enough insulin Illness Too much food Infection Decreased activity Stress Symptoms Mild to Moderate Thirsty Fatigue Nausea Hunger Vomiting Stomach pains Blurred vision Dry mouth Fruity breath Frequent urination Lack of concentration Parent to circle usual symptoms Severe Mild to moderate symptoms plus: Prolonged vomiting Rapid, labored breathing Rapid heart Very weak Confused Unconscious Actions Notify school nurse or trained personnel to test the blood glucose and to test the urine for ketones. If the blood glucose is high and the student is able to return to class, allow him/her to drink water or carbohydrate-free fluids and use the bathroom as needed. 3/15/2010

14 Hypoglycemia (Low Blood Glucose) Emergency Plan for a Student with Diabetes on Basal/Bolus or Insulin Pump Therapy School Year Student s Name Address Date of Birth School Name Grade Teacher Mother/Guardian Father/Guardian Home Phone Work Phone Cell Phone Home Phone Work Phone Cell Phone Causes of Hypoglycemia Too much insulin Delayed food Missed food Exercise Symptoms Mild to Moderate Hungry Irritable Headache Sweaty Shaky Weak Blurred vision Anxious Other Parent to circle usual symptoms Severe Loss of consciousness Seizure Inability to swallow Actions Never send a student with suspected low blood glucose anywhere alone. Notify school nurse or trained personnel. If possible, test blood glucose. Treat if 70 mg/dl or less (80 mg/dl or less if student under six years of age). If unable to test but student is symptomatic, TREAT. Treatment of Mild to Moderate Immediately give a fast-acting carbohydrate such as: 4 oz. fruit juice or 4 oz regular pop or 5-8 lifesaver candies or 3-4 glucose tablets or 3 packets of sugar Wait 15 minutes. Retest the blood glucose. Repeat treatment and retest every 15 minutes until the blood glucose is greater than 70 mg/dl (80 mg/dl if student under six years of age). Contact the parents/guardians if the student required a repeat treatment or if the blood glucose was less than 50 mg/dl or if the student had more than one episode of hypoglycemia during the school day. Treatment of Severe Don t attempt to give anything by mouth. Position on side, if possible. Have trained personnel mix and administer glucagon, as prescribed. Call 911. Stay with the student. Contact the parents/guardians. When the student awakens and can swallow, encourage the student to take small sips of fruit juice or regular pop. If tolerated, follow with a snack consisting of a carbohydrate and a fat, such as peanut butter crackers. 3/15/2010

15 CALCULATION SHEET FOR RAPID ACTING INSULIN BOLUS Date Time 1. Calculate Carbohydrate Bolus: = Carbohydrates CARBOHYDRATE Carbohydrate Bolus to Eat RATIO (Round to nearest tenth) 2. Calculate Correction Bolus: - = = Blood CORRECTION Amount to CORRECTION Correction Glucose TARGET Correct FACTOR Bolus (Round to nearest tenth) 3. Calculate Total Insulin Bolus: + + = Carbohydrate Correction Ketone Bolus Total *Rounded Total Bolus Bolus (if applicable) Insulin Bolus Date Time 1. Calculate Carbohydrate Bolus: = Carbohydrates CARBOHYDRATE Carbohydrate Bolus to Eat RATIO (Round to nearest tenth) 2. Calculate Correction Bolus: - = = Blood CORRECTION Amount to CORRECTION Correction Glucose TARGET Correct FACTOR Bolus (Round to nearest tenth) 3. Calculate Total Insulin Bolus: + + = Carbohydrate Correction Ketone Bolus Total *Rounded Total Bolus Bolus (if applicable) Insulin Bolus * Use this chart for Rounded Total Insulin Bolus Food Grams of Carbs ROUNDING RULE for ½ Unit: = Round down to whole unit = Round to ½ unit = Round up to whole unit Food Grams of Carbs Total ROUNDING RULES for Whole Unit: = Round down to whole unit = Round up to whole unit Total CARBOHYDRATE RATIO How many grams of carbohydrates will be covered by one unit of insulin. CORRECTION FACTOR How many points one unit of insulin will lower the blood glucose. CORRECTION TARGET Target blood glucose value used for insulin dose calculations. KETONE BOLUS Amount of insulin to treat ketones. (Refer to Self-Management of Ketones and Sick Day Flowcharts) NO CORRECTION RULES DO NOT CALCULATE CORRECTION BOLUS: If your blood glucose is less than your CORRECTION TARGET. If it has been less than three hours since your last carbohydrate bolus or correction bolus. If you have treated a low blood glucose in the past three hours. If it has been less than one hour since vigorous exercise. At bedtime or during the night until directed otherwise.

16 GLUCAGON EMERGENCY KITS When your child has a severe low blood glucose, you and your family members will need to act quickly. Become familiar with the instructions for using the Glucagon Emergency Kit before a low blood glucose happens. The kit contains everything you need in case your child has a severe low blood glucose. The kit includes a bottle of glucagon (the dry powder) and a syringe of clear liquid. Glucagon is safe; it is a hormone made in the pancreas and raises blood glucose. There is no danger of taking too much. Possible side effects are nausea and vomiting. Glucagon Emergency Kit manufactured by Eli Lilly and GlucaGen HypoKit manufactured by Novo Nordisk If your child is unconscious, having uncontrolled jerking (seizures), or can't swallow, you should always give glucagon -- even if you are not sure your child's blood glucose is low. Points to Remember Storage: Store glucagon at controlled room temperature (68-77 o ). Never leave glucagon in direct sunlight. Refer to package insert for further instructions. Expiration date: Check the manufacturer s expiration date on the kit or on the vial that contains the glucagon powder at the time of purchase. Write the expiration date of your kit on your calendar. When your kit expires, practice mixing and drawing up glucagon before throwing it away. After mixing, solution should be clear and used immediately. Discard any unused portion and reorder kit. DFC Approved 1/17/2012

17 HOW TO USE THE GLUCAGON EMERGENCY KIT Here are step-by-step directions for using the Glucagon Emergency Kit. It is important that you and your family members or friends read these instructions carefully. 1. Remove the flip-off seal from the bottle of glucagon. 2. Remove the needle protector from the syringe, and inject the entire contents of the syringe into the bottle of glucagon. 3. Remove the syringe and gently shake bottle until liquid is clear. 4. Using the same syringe, draw the glucagon into the syringe to the prescribed dose. 5. Insert the needle into your child's thigh and inject the entire contents of the syringe. Withdraw the needle from the skin. Turn your child onto his or her side, in case of nausea and vomiting. 6. Call When the child awakens and can swallow, encourage the child to take small sips of a carbohydrate containing fluid (fruit juice or regular soft drink). If tolerated, follow with 15 grams of carbohydrate and a fat containing food (such as cheese and crackers). 8. Notify your diabetes healthcare provider that your child had a severe low blood glucose before the next insulin dose. DFC Approved 1/17/2012

18 Diabetes Monitoring Log for Students at School Student s Name: Address: Date of Birth: School Name: Grade: Parent(s) Name: Phone: Phone: Type of insulin therapy: Split/Mixed Insulin Pump Basal/bolus Carb ratio for food: 1 unit for grams of carbohydrates Correction target BG: mg/dl Correction factor: 1 unit for every mg/dl above correction target Insulin pen cartridge/vial change dates: Date Time Blood Glucose Insulin dose Ketones (neg, S, M, or L) Comments (note any unusual circumstances, i.e. extra food intake, hypoglycemia treatment, physical activity, change in routine, illness) Initials Signature of staff providing care Initials Signature of staff providing care Initials Signature of staff providing care Initials 2/16/2012

19 Diabetes ID Sheet Insulin Pump Therapy School Year My Photo Student Address Date of Birth School Grade I have diabetes and my pancreas does not make insulin. Without insulin, the food (carbohydrates) that I eat cannot be used for energy. To manage my diabetes, I require injections of insulin. Several times a day I must check my blood glucose level. It is important that you understand some facts about diabetes while I am in your care. Please review this and keep it as a reference. MEALS AND SNACKS My blood glucose is affected by the food (carbohydrates) that I eat. I have no dietary restrictions, but I need an insulin injection when I eat food that contains carbohydrates. ACTIVITY My blood glucose is also affected by activity. I may need an extra snack (carbohydrates) before, during, or after a strenuous activity. In this case, I do not need to take insulin. LOW BLOOD GLUCOSE Occasionally, my blood glucose may become too low. This is most likely to occur just before lunch, after strenuous activity, if my meal/snack is delayed, or if I don t eat enough food (carbohydrates). If my blood glucose becomes too low, I may have the following signs/symptoms: Hunger Irritability Behavior Change Headache Shakiness Sweat Lack of concentration Drowsiness Paleness Weakness Confusion Poor coordination If this happens I NEED A FAST-ACTING CARBOHYDRATE You can give me You will find this Recheck blood glucose in 15 minutes Repeat carbohydrates if symptoms persist or blood glucose is less than md/dl If my blood glucose drops to a severe low, I may become unconscious or have a seizure. DO NOT attempt to give me anything by mouth Position me on my side if possible Administer glucagon (if available) by trained personnel Call 911 Contact my parent(s)/guardian Stay with me EMERGENCY NUMBERS: Mother: Home phone Work phone Cell phone Father: Home phone Work phone Cell phone Other (relationship) Home phone Work phone Cell phone