Revised 08.13.09
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 should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel.
Effective Dates: ___________________________________________________________ Student’s Name: ___________________________________________________________ Date of Birth: _________________________ Date of Diabetes Diagnosis:______________ Grade:______________________________ Homeroom Teacher: ____________________ Physical Condition: Diabetes type 1 Diabetes type 2
Contact Information
Mother/Guardian: _________________________________________________________ Address: ________________________________________________________________ Telephone: ______________________________________________________________ Father/Guardian: __________________________________________________________ Address: ________________________________________________________________ Telephone: H:___________________W:________________________C:______________ Student’s Doctor/Health Care Provider: Name: __________________________________________________________________ Address: ________________________________________________________________ Telephone: ______________________________________________________________ Other Emergency Contacts: Name: ________________________________________________________________ Relationship: ______________________________________________________________ Telephone: Home _________________ Work _____________ Cell __________________ Notify parents/guardian or emergency contact in the following situations:_________________________________________________________________
Blood Glucose Monitoring
Target range for blood glucose is 70-150 70-180 Other ______________ Usual times to check blood glucose____________________________________________. Times to do extra blood glucose checks (check all that apply) Before exercise After exercise When student exhibits symptoms of hyperglycemia When student exhibits symptoms of hypoglycemia Testing:_______________________________________________________ Can student perform own blood glucose checks? Yes No Exceptions: ______________________________________________________________ Type of blood glucose meter student uses: ______________________________________
Revised 08.13.09
Insulin Usual Lunchtime Dose
Base dose of Humalog/Novolog /Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is _____ units or does flexible dosing using _____ units/ _____ grams carbohydrate. Use of other insulin at lunch: (circle type of insulin used): intermediate/NPH/ _____ units or basal/Lantus/Levimer _____ units. Insulin Correction Doses Parental authorization should be obtained before administering a correction dose for high blood glucose levels. Yes No ___________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 _____ to _____ mg/dl ___________units if blood glucose is _____ to _____ mg/dl Can student give own injections? Yes No Can student determine correct amount of insulin? Yes No Can student draw correct dose of insulin? Yes No _______ Parents are authorized to adjust the insulin dosage under the following circumstances: When circumstances seem unusual or whenever a trend indicates flexibility is required.
For Students with Insulin Pumps
Type of pump: Type of insulin in pump: Type of infusion set: Insulin/carbohydrate ratio: Correction factor: Student Pump Abilities/Skills: Count carbohydrates Bolus correct amount for carbohydrates consumed Calculate and administer corrective bolus Calculate and set basal profiles Calculate and set temporary basal rate Disconnect pump Reconnect pump at infusion set Prepare reservoir and tubing Insert infusion set Troubleshoot alarms and malfunctions
Needs Assistance Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No No No
For Students Taking Oral Diabetes Medications
Type of medication: _______________________________ Timing: ________________ Other medications: ______________________________ Timing: ________________ Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management? Yes No Meal/Snack Time Food content/amount Breakfast _______________ ___________________________________ Mid-morning snack _______________ ___________________________________ Lunch _______________ ___________________________________ Mid-afternoon snack _______________ ___________________________________ Dinner _______________ ___________________________________ Snack before exercise? Yes No Depending on BG Snack after exercise? Yes No Depending on BG Other times to give snacks and content/amount: ______________________________________ Preferred snack foods: ______________________________________________________
Revised 08.13.09
Foods to avoid, if any: _______________________________________________________ Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event): Call parent whenever possible to coordinate, if not, have nutritional values of food so carbohydrate count can be determined.
Exercise and Sports
A fast-acting carbohydrate such as ________________________________________ should be available at the site of exercise or sports. Restrictions on activity, if any:__________________________________ student should not exercise if blood glucose level is below _____ mg/dl or above_______ mg/dl or if moderate to large urine ketones are present. Hypoglycemia (Low Blood Sugar) Usual symptoms of hypoglycemia:_____________________________________________ _________________________________________________________________________ Treatment of hypoglycemia:__________________________________________________ Glucagon should be given if the student is unconscious, having a seizure (convulsion), or unable to swallow. Route:_____, Dosage:_____, site for glucagon injection: ___________________________ If glucagon is required, administer it promptly. Then, call 911 (or other emergency assistance) and the parents/guardian. Hyperglycemia (High Blood Sugar) Usual symptoms of hyperglycemia: ___________________________________________ Treatment of hyperglycemia:_________________________________________________ Urine should be checked for ketones when blood glucose levels are above ________ mg/dl. Treatment for ketones:_______________________________________________________ Supplies to be Kept at School _______Blood glucose meter, blood glucose test strips, batteries for meter _______Lancet devices, lancets, gloves, etc. _______Urine ketone strips _______Insulin pump and supplies _______Insulin pen, pen needles, insulin cartridges _______Fast-acting source of glucose _______Carbohydrate containing snack _______Glucagon emergency kit
Signatures
This Diabetes Medical Management Plan has been approved by: ______________________________________________ _______________________ Student’s Physician/Health Care Provider Date 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 ______________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 Date ______________________________________________ ______________________ Student’s Parent/Guardian Date
Revised 08.13.09
DIABETES SELF-MEDICATION AUTHORIZATION FORM
SCHOOL YEAR __________________ Student’s Name __________________________________ Phone ____________________ 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 self-monitoring 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 read Protocol for Physician Signature blood glucose testing and I judge that my son/daughter named above has Date
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 selfadministration 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
Date
Revised 08.13.09
Medical Statement for Students with Special Nutritional Needs for School Meals
Part A (To be completed by Parent/Guardian)
Name of Student: (Last) ___________________ S Student ID # _______________ Will student eat breakfast at school? Yes No (First) _______________________ (Middle) ____ Grade ______ School ____________________________________ Will student eat lunch at school? Yes No
Will student eat snack in the after school program? Yes No
Name of Parent/Guardian: ______________________________________________________________ Mailing Address: _________________________ Phone number(s): __________ (W)
Does Does the child have an identified disability? Yes No If yes Describe the major life activities affected by the disability: Does the child have special nutritional or feeding needs? Yes No If Yes, have a licensed physician complete Part B of this form and sign it.
City: ________________ _________________ (H)
State/Zip: __________
________________ (Cell)
If the child does not have an identified disability, does the child have special nutritional or feeding needs? Yes No 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
Date
Part B Diet Order (To be completed by Physician)
S Specify any dietary restrictions or special diet:
List any foods that cause food allergies or intolerances that should be avoided: If student has life threatening allergies, check appropriate box(es): ingestion
Designate consistency requirements for food: Blenderized Liquid Puree Thin
contact
Nectar-thick
inhalation
Designate consistency requirement for liquids:
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
Indicate any other comments about the child’s eating or feeding patterns:
Signature of physician/medical authority*
must sign the form.
Printed name
Telephone number
Date
*A licensed physician’s sign ature is required for participants with a disability. For participants without a disability, a licensed physician or medical authority
Part C (To be completed by Child Nutrition Services)
Child Nutrition Services Notes: CN Administrator Signature: _________________________________ Date: ______________________
“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. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (T)
Revised 08.13.09
PHYSICIAN’S SCHOOL MEDICATION FORM
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 at: ________________________________________ c) Other option: __________________________________________________________________________ The medication for this pupil from me will be properly labeled and will carry my name as the prescribing physician. Date_______________ 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
___________________________________________________________________
Date
___________________
Principal’s Signature
FOR SCHOOL USE ONLY
Date
Date Physician’s School Medication Form Expires: _________________________________________ Please be reminded form will expire one (1) year from date of Physician’s signature.
Revised 08.13.09
PHYSICIAN’S SCHOOL MEDICATION FORM
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.
Date
RELEASE OF LIABILITY FORM
Physician’s Signature
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 ____________________________________ Date _____________________________________ Date
FOR SCHOOL USE ONLY Date Physician’s School Medication Form Expires: _________________________________________ Please be reminded form will expire one (1) year from date of Physician’s signature.