Maryland State Management Of Diabetes At School/order Form

Maryland State Supplemental Form for Students with Insulin Pumps

This order is valid only for the Current School Year:______ (including summer session)

Student: ______________________________

DOB: ___________________

School: _______________________________

Grade: _________

CONTACT INFORMATION:

Parent/Guardian: _____________________ Home Phone: __________ Work: __________ Cell/pager: ___________

Pump Resource Person: ______________________ Phone: ______________________________

Other Emergency Contact: __________________________________

Pump Management

Type of pump: ______________________ Start Date for Pump Therapy: __________________________

Type of Insulin in pump: _________________________

Basal rates:

____________ 12am to ___________

Comment: ____________________

_____________ _______ ___________

Insulin/carbohydrate ratio:

_______

Check Management of Diabetes at School Order or correction factor

Hyperglycemia:

____ Pump site should be changed if BG greater than _____________ times _______________

____ Insulin should be given by syringe or pen if needed _______________________________

Management Skills of Student

•

As verified by school nurse, health care provider and parent

Independent?

Count carbohydrates

__ yes

__ no

Calculate an insulin dose

__ yes

__ no

Bolus an insulin dose

__ yes

__ no

Reset basal rate profiles

__ yes

__ no

Set a temporary basal rate

__ yes

__ no

Disconnect pump

__ yes

__ no

Reconnect pump at infusion set

__ yes

__ no

Prepare infusion set for insertion

__ yes

__ no

Insert infusion set

__ yes

__ no

Troubleshoot alarms and malfunctions

__yes

__ no

Give self injection if needed

__ yes

__ no

Change batteries

__ yes

__ no

__ Student is non-independent Child Lock On?

Yes

Pump Supplies

Extra supplies needed include: Infusion sets, reservoir/cartridges, insertion device, insulin vial & syringes, batteries

Location of supplies: _________________________________________________________________________

Disaster Plan (If needed for lockdown, etc):

Follow Insulin orders as on Management Form

Insulin doses as follows: _________________________

Other: ___________________________________________________

Health Care Provider's Signature: ______________________________ Date: ________________

Parent’s Signature: ______________________________________

Date: ________________

Order reviewed by School Nurse (per local policy):

Date: ________________

MSDE8/10

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Maryland State Management Of Diabetes At School/order Form - 2004 Page 3

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