Diabetes Medication Administration Form printable pdf download

Diabetes Medication Administration Form

Instructions: This form is updated annually to document physician approval regarding the following:



Administration of glucagon by school staff



Administration of insulin by school staff for a student not able to complete the task (NSS Delegated

Care)



Supervision by school staff of a student self-administering insulin who is not yet fully independent in

the task (NSS Delegated Care)

Student Name: _______________________________________ Date of Birth: _____________________

School: __________________________________ Care Card Number: ___________________________

Parent/Guardians’ Name(s): ______________________________________________________________

Home Phone: ____________________________ Cell Phone: ___________________________________

Glucagon (GlucaGen® or Lilly Glucagon™)

For severe low blood glucose, give by intramuscular injection:



0.5 mg = 0.5 ml for students 5 years of age and under



1.0 mg = 1.0 ml for students 6 years of age and over

Insulin (rapid acting insulin only)



Insulin delivery device:

insulin pump

insulin pen

Note: The following cannot be accommodated when insulin administration is being delegated to a school

staff person via pump or pen:



Overriding the calculated dose



Entering an altered carbohydrate count for foods in order to change the insulin dose



Changing the settings on the pump



Deviating from the NSS Delegated Care Plan

For students using an insulin pen, insulin may be administered at lunchtime only (due to the

inability to accurately calculate insulin on board). The method of calculating the dose is as follows:



Bolus Calculator Sheet



Variable dose insulin scale for blood glucose for consistent carbohydrates consumed



InsuLinx® Meter



Parent/guardian authority to adjust insulin dose for bolus calculator sheet or sliding scale:

Yes

For students using an insulin pump, insulin can be given if needed at recess, lunch and two hours

after lunch (as there is an ability to know the insulin on board).



I agree the student’s diabetes can be safely managed at school within the above parameters

Physician Signature: ___________________________________ Date: ________________________

Physician Name: ______________________________Clinic Phone Number: ___________________

Diabetes Medication Administration Form

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