Blood Glucose Testing Consent/verification Child Care Facilities
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1STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
BLOOD GLUCOSE TESTING CONSENT/VERIFICATION
CHILD CARE FACILITIES
This form may be used to show compliance with Health and Safety Code Section 1596.797 before a child care licensee or
staff person performs blood glucose testing on a child in care diagnosed with diabetes. A copy of the completed form
should be filed in the child’s record and in the personnel file. A separate form must be filled out for each person who
performs blood glucose testing on the child.
I,_________________________________________, give my consent for_______________________________________,
(PRINT NAME OF AUTHORIZED REPRESENTATIVE)
(PRINT NAME OF LICENSEE OR STAFF PERSON)
who work(s) at ____________________________________________________________________________________,
(PRINT NAME AND ADDRESS OF CHILD CARE FACILITY)
to perform blood glucose testing on my child,_________________________________, and to contact my child’s health
(PRINT NAME OF CHILD)
care provider.
In addition, I certify that I have personally instructed the above-named licensee or staff person on how to perform blood
glucose testing on my child.
I have also provided the child care facility with written instructions from my child’s physician, or from a health care provider
working under the supervision of my child’s physician (for example, a physician’s assistant, nurse practitioner or registered
nurse). These instructions include:
•
The blood glucose test must be approved by the Federal Food and Drug Administration.
•
Specific written directions for performing blood glucose testing in accordance with the physician’s prescription.
•
Potential side effects and expected response.
•
Actions to be taken in the event of side effects or incomplete treatment response in accordance with the physician’s
prescription. This includes actions to be taken in an emergency.
•
Instructions for proper storage of the medication.
•
The telephone number and address of the child’s physician.
SIGNATURE OF AUTHORIZED REPRESENTATIVE
DATE
ADDRESS OF AUTHORIZED REPRESENTATIVE
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
LIC 9222 (9/05)
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