School Diabetes Action Plan Form Page 2
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4DUBLIN UNIFIED SCHOOL DISTRICT
SCHOOL DIABETES ACTION PLAN
Student Information
Name of Student: ___________________________ DOB: ________________ Grade: ___________
st
School: ________________________ Teacher/1
Period Teacher: __________________________
Physical Education Days and Times: __________________________________________________
Emergency Information
Parent/guardian Name: ________________________________Phone: (H)____________________
Phone: (C) ____________________
Address: ______________________________Phone: (W)____________________
Parent/guardian Name: ________________________________ Phone: (H)____________________
Phone: (C) ____________________
Address: _______________________________Phone: (W)____________________
Physician’s name: ________________________________ Phone: _______________________
Diabetic Educator: ________________________________ Phone: __________________________
Emergency Phone Contact #1_____________________ _____________________ _____________
Name
Relationship
Phone
Emergency Phone Contact #2_____________________ _____________________ _____________
Name
Relationship
Phone
The following must be completed by the physician and returned to the school office:
Target Range of Blood Glucose _____________
Specific dietary guidelines
Meal/snack times:
Breakfast _________
AM Snack ________
Lunch___________
PM Snack_________
Dinner ___________
Bed ____________
Blood Glucose Testing at School:
Student is able to test his/her own blood glucose? ____Yes
____ No
Adult verifies results? ____Yes
____ No
Needs assistance? (specify) ___________________________________________________
Type of Meter: ___________________________
Test strip required: _________
Student should be allowed to carry meter? ____Yes
____ No
Routine testing times at school: ____ AM
____ Noon
____ PM
Supplemental testing times:
____ Before exercise ____After exercise ___ Before snacks
____ With symptoms of high/low blood glucose
Other: ____________________
Notify Parent/Guardian of results when:___________________________________________
Health/Diabetic Action Plan 7/10
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