Diabetes Action Plan Form Page 4
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1
2
3
4SUPPLIES
T O
B E
K EPT
A T
S CHOOL
________
Blood
g lucose
m eter,
b lood
g lucose
t est
s trips,
b atteries
f or
m eter
________
Lancet
d evice,
l ancets,
g loves,
e tc.
________
Urine
k etone
s trips
________
Insulin
p ump
a nd
s upplies
________
Insulin
p en,
p en
n eedles,
i nsulin
c artridges
________
Fast-‐acting
s ource
o f
g lucose
_ _______
Carbohydrate
c ontaining
s nack
________
Glucagon
e mergency
k it
Location
o f
S upplies
w hile
a t
s chool:
_ ____________________________________________________________________________
This
D iabetes
A ction
P lan
h as
b een
a pproved
b y:
_____________________________________________________
________________________________
Student’s
P hysician/Health
C are
P rovider
Date
I
g ive
p ermission
t o
t he
s chool
n urse,
t rained
d iabetes
p ersonnel,
a nd
o ther
d esignated
s taff
m embers
o f
D istrict
1 45
t o
p erform
a nd
carry
o ut
t he
d iabetes
c are
t asks
a s
o utlined
b y
( student’s
n ame)
_ ____________________________________________________’s
Diabetes
A ction
P lan.
I
a lso
c onsent
t o
t he
r elease
o f
t he
i nformation
c ontained
i n
t his
D iabetes
A ction
P lan
t o
a ll
s taff
m embers
a nd
other
a dults
w ho
h ave
c ustodial
c are
o f
m y
c hild
a nd
w ho
m ay
n eed
t o
k now
t his
i nformation
t o
m aintain
m y
c hild’s
h ealth
a nd
safety.
I
a lso
a uthorize
t he
s chool
n urse
t o
d iscuss
t his
D iabetes
A ction
P lan
a nd
m atters
p ertinent
t o
( student’s
n ame)
_______________________________________________________’s
d iabetic
c ondition
w ith
t he
a bove-‐named
h ealth
c are
p rovider.
Parent/Guardian
S ignature
_ _______________________________________________________
Date
_ ________________
*A
D iabetes
A ction
P lan
f rom
t he
d octor
c an
r eplace
t his
p lan
h owever
i t
m uch
i nclude
a ll
p ertinent
i nformation.
*Either
A ction
P lan
u sed
m ust
i nclude:
*Please
p rovide
c opies
t o
a ll
s taff
t hat
w ork
w ith
t he
s tudent
t hroughout
t he
d ay
*Attached
I HP,
I EP,
5 04,
S AT
P lan,
e tc.,
i f
a pplicable
*Diabetes
L ogs
s hould
b e
a ttached
t o
o r
k ept
w ith
t his
p lan
t o
m onitor
a ctivity
a t
s chool.
*Medication
A dministration
A uthorization
F orms
a ttached,
i f
a pplicable.
*Self
M anagement
F orm,
i f
a pplicable.
Updated
5 /1/14
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