School Diabetes Action Plan Form (Page 4 of 4) in pdf

DUBLIN UNIFIED SCHOOL DISTRICT

SCHOOL DIABETES ACTION PLAN

Name: __________________________________

 Treatment of HIGH BLOOD GLUCOSE: (See signs & symptoms of high blood glucose)

Student’s blood sugar is considered high if BS is ______ mg/dl or higher.

1. Urine ketones checked at school? ____ No; _____Yes if blood glucose is above _____

_____student checks ketones independently

______ with assistance

2. Notify parents or physician if ketones are positive or when _____________________________

3. Additional actions to be taken: ___________________________________________________

4. Recheck blood glucose every ______ minutes. Student may return to class when blood

glucose is ______ or should be sent home when: ____________________________________

 Specific Sports/Exercise guidelines:

1. Student may participate in daily PE? _____ Yes

____ No

2. Blood Glucose testing before PE?

_____ Yes

____ No

3. Exercise should be delayed or avoided if blood glucose is higher than______ mg/dl

or lower than_____ mg/dl.

4. Student may participate in after school sports? ____ Yes

____ No

5. Activity Restrictions: ____ None

____ Other: ____________________________



Field Trips, all diabetic supplies are taken on trip and care is provided according to this Diabetes

Action Plan.

See Diabetic Preparation for Field Trip Form for listing of items needed and guidelines.

 Classroom/School Parties, food treats shall be handled as follows:

____ Student will eat the treat

____ Replace with parent supplied alternative

____ Put in baggie and take home with teacher note ____ Modify treat as follows______________

 3 Day Disaster Emergency Preparedness:

Parents to provide the following:

(Should be kept in accessible location, available at all times)

□ 1 vial /pen of insulin: _______________________

□ Syringes/pen needles



□ Blood GlucoseTest kit with lancets, meter & strips

□ Snacks & Juice

□ Glucose Gel

□ Glucagon Kit

□ Glucose Tablets

In case of EMERGENCY/DISASTER:

Give _____ units of ____________________ SQ, at (time)__________

Parent Consent for Diabetes Management In School

As parent/guardian of above named student, I request that the above Specialized Physical Health Care Service for

management of diabetes in school be administered to student, in accordance with CA. Ed. Code 49423.5. I will:

1. Provide the necessary supplies and equipment.

2. Notify the school nurse if there is a change in students health status, orders, or attending physician.

3. Notify the school nurse immediately and provide new consent & supplies for any changes in doctor’s orders.

4. I authorize the school nurse to communicate with the Physician or Diabetes Educator when necessary.

Parent/Guardian Signature: ______________________________________ Date: ______________

Physician Consent for Diabetes Management in School

My signature below provides authorization for the above written orders. I understand that Specialized Physical Health

Care Services may be performed by unlicensed designated school personnel under the training and supervision of the

district nurse. The authorization is for a maximum of one year.

Physician’s Signature: ___________________________________________ Date: __________________

Reviewed by District Nurse: _______________________________________ Date: __________________

Health/Diabetic Action Plan 7/10

School Diabetes Action Plan Form Page 4

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