APPENDIX C (AP ) P AN OF CARE T PE DIA ETES STUDENT INFORMATION Student Name Date Of Birth Ontario Ed. Age Student Photo optional Grade Teacher s EMER ENC CONTACTS IST IN PRIORIT NAME RE ATIONSHIP DAYTIME PHONE A TERNATE PHONE 1. 2. 3. T PE DIA ETES SUPPORTS Names of trained individuals ho ill provide support ith diabetes-related tas s: e.g. designated staff or community care allies. Method of home-school communication: Any other medical condition or allergy
DAI ROUTINE T PE DIA ETES MANA EMENT Student is able to manage their diabetes care independently and does not re uire any special care from the school. Yes No If Yes go directly to page five 5 Emergency Procedures ROUTINE ACTION OOD UCOSE MONITORIN Target Blood Glucose Range Student re uires trained individual to chec BG/ read meter. Student needs supervision to chec BG/ read meter. Student can independently chec BG/ read meter. Student has continuous glucose monitor CGM Students should be able to chec blood glucose anytime anyplace respecting their preference for privacy. NUTRITION REA S Student re uires supervision during meal times to ensure completion. Student can independently manage his/her food inta e. Reasonable accommodation must be made to allo student to eat all of the provided meals and snac s on time. Students should not trade or share food/snac s ith other students. Time s to chec BG: Contact Parent s /Guardian s if BG is: Parent s /Guardian s Responsibilities: School Responsibilities: Student Responsibilities: Recommended time s for meals/snac s: Parent s /Guardian s Responsibilities: School Responsibilities: Student Responsibilities: Special instructions for meal days/ special events: Page 2 of
ROUTINE ACTION CONTINUED INSU IN ocation of insulin: Student does not ta e insulin at school. Re uired times for insulin: Student ta es insulin at school by: In ection Before school: Morning Brea : Pump unch Brea : Afternoon Brea : Insulin is given by: Student Other Specify : Student ith supervision Parent s /Guardian s responsibilities: Parent s /Guardian s Trained Individual School Responsibilities: All students ith Type 1 diabetes use insulin. Some Student Responsibilities: students ill re uire insulin during the school day typically Additional Comments: before meal/nutrition brea s. ACTIVIT P AN Physical activity lo ers blood glucose. BG is often chec ed before activity. Carbohydrates may need to be eaten before/after physical activity. A source of fast-acting sugar must al ays be ithin students reach. Please indicate hat this student must do prior to physical activity to help prevent lo blood sugar: 1. Before activity: 2. During activity: 3. After activity: Parent s /Guardian s Responsibilities: School Responsibilities: Student Responsibilities: For special events notify parent s /guardian s in advance so that appropriate ad ustments or arrangements can be made. e.g. extracurricular Terry Fox Run Page 3 of
ROUTINE DIA ETES MANA EMENT IT Parents must provide maintain and refresh supplies. School must ensure this it is accessible all times. e.g. field trips fire drills loc do ns and advise parents hen supplies are lo. ACTION CONTINUED its ill be available in different locations but ill include: Blood Glucose meter BG test strips and lancets Insulin and insulin pen and supplies. Source of fast-acting sugar e.g. uice candy glucose tabs. Carbohydrate containing snac s Other Please list ocation of it: SPECIA NEEDS Comments: A student ith special considerations may re uire more assistance than outlined in this plan.
EMER ENC PROCEDURES H PO CEMIA O OOD UCOSE ol or less DO NOT EAVE STUDENT UNATTENDED Usual symptoms of Hypoglycemia for my child are: Sha y Irritable/Grouchy Dizzy Trembling Blurred Vision Headache Hungry Wea /Fatigue Pale Confused Other Steps to ta e for Mild Hypoglycemia student is responsive 1. Chec blood glucose give grams of fast acting carbohydrate e.g. cup of uice 15 s ittles 2. Re-chec blood glucose in 15 minutes. 3. If still belo 4 mmol/ repeat steps 1 and 2 until BG is above 4 mmol/. Give a starchy snac if next meal/snac is more than one 1 hour a ay. Steps for Severe Hypoglycemia student is unresponsive 1. Place the student on their side in the recovery position. 2. Call 9-1-1. Do not give food or drin cho ing hazard. Supervise student until emergency medical personnel arrives. 3. Contact parent s /guardian s or emergency contact H PER CEMIA HI H OOD OCOSE MMO OR A OVE Usual symptoms of hyperglycemia for my child are: Extreme Thirst Fre uent Urination Headache Hungry Abdominal Pain Blurred Vision Warm Flushed S in Irritability Other: Steps to ta e for Mild Hyperglycemia 1. Allo student free use of bathroom 2. Encourage student to drin ater only 3. Inform the parent/guardian if BG is above Symptoms of Severe Hyperglycemia Notify parent s /guardian s immediately Rapid Shallo Breathing Vomiting Fruity Breath Steps to ta e for Severe Hyperglycemia 1. If possible confirm hyperglycemia by testing blood glucose 2. Call parent s /guardian s or emergency contact
HEA THCARE PROVIDER INFORMATION OPTIONA Healthcare provider a include: Physician Nurse Practitioner Registered Nurse Pharmacist Respiratory Therapist Certified Respiratory Educator or Certified Asthma Educator. Healthcare Provider s Name: Profession/Role: Signature: Date: Special Instructions/Notes/Prescription abels: If medication is prescribed please include dosage fre uency and method of administration dates for hich the authorization to administer applies and possible side effects. This information may remain on file if there are no changes to the student s medical condition. AUTHORI ATION P AN REVIE INDIVIDUA S WITH WHOM THIS P AN OF CARE IS TO BE SHARED 1. 2. 3. 4. 5. 6. Other individuals to be contacted regarding Plan Of Care: Before-School Program Yes No After-School Program Yes No School Bus Driver/Route If Applicable Other: This plan re ains in e ect or the 2 2 school ear without change and will e reviewed on or e ore It is the parent s /guardian s responsibility to notify the principal if there is a need to change the plan of care during the school year. Parent s /Guardian s : Signature Student: Signature Principal: Signature Date: Date: Date: