Diabetes Medication Administration Form


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
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:
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: ___________________


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