School Diabetes Action Plan Form printable pdf download

School Diabetes Action Plan Form

DUBLIN SCHOOLS

DUBLIN UNIFIED SCHOOL DISTRICT

Diabetes Action Plan

Dear Parent/Guardian,

Enclosed is a “Diabetes Action Plan” form that will serve as your child’s individualized treatment plan

to help us effectively meet his or her diabetic needs while at school. This form will need to be

completed by you and your child’s physician, and returned to the school office on or before the start

of school, or when changes occur to the current plan. Parents are encouraged to review the

“Diabetes Action Plan” with their child’s physician and check that all sections have been completed.

Please take the enclosed form to your child’s physician and return it to the school office, along with

any equipment, medication and snacks necessary to follow the physician’s orders. It is in your child’s

best interest to have this form completed and have the diabetic supplies at school, prior to the

beginning of the school year.

For those students requiring supplemental insulin during school hours via syringe or insulin pump,

please have your child’s physician include the dosage of insulin based on blood glucose reading. If

self-administration of insulin has been prescribed at school, trained staff will supervise the self-

administration of insulin by your student unless otherwise indicated.

If you have any questions or concerns, please call the District Nurse at (925) 828-2551, ext. 8036.

Dublin Unified School District Nurse

School Diabetes Action Plan Form