Information For Diabetes Management At School - Auburn Washburn Unified School
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1
2INFORMATION FOR DIABETES MANAGEMENT AT SCHOOL
Dear Parent,
Since you have shared with us that your child has diabetes, completion of the following will
help us form a plan of care for school. We want to ensure effective treatment delivery and
safety for your child while at school.
Shuler Education Center
Student Name: ___________________________________________ DOB:_________________
5928 SW 53rd Street
Parent/Guardian: _______________________________________________________________
Topeka, KS 66610-9451
Home Phone: __________________Work:_______________________ Cell:________________
785.339.4000
Emergency Contact: ________________________________ Relationship:__________________
785.339.4025 fax
Physician:____________________________________ Phone:___________________________
Insulin Administration:
Dr. Brenda S. Dietrich
______ Syringe and Insulin
Vial Brand name: ________________________
Superintendent
______ Insulin Pen
______ Insulin Pump
Other:______________________
Dr. Ann L. Matthews
Executive
Director
Insulin: AM
_____________________
Lunch
___________________
Teaching & Learning
(Time‐Type‐Amount)
(Time‐Type‐Amount)
Bruce Petersen
Dinner _____________________
Bedtime ___________________
Executive Director
(Time‐Type‐Amount)
(Time‐Type‐Amount)
Human Resources
& Operations
Bruce Stiles, CPA
Will student require assistance with insulin administration?
___ yes ___ no
Director of Business
If so, please note what type of assistance is needed.
Services
______________________________________________________________________________
For Students With Insulin Pumps:
Type of pump: _________________________________ Basal rates: ______________________
Type of insulin in pump: __________________________________________________________
Type of infusion set: _____________________________________________________________
Insulin/carbohydrate ratio: ________________ Correction factor: ________________________
Student Pump Abilities/Skills:
Needs Assistance
Count carbohydrates
___ yes ___ no
Bolus correct amount for carbohydrates consumed
___ yes ___ no
Calculate and administer corrective bolus
___ yes ___ no
Calculate and set temporary basal rate
___ yes ___ no
Disconnect pump
___ yes ___ no
Reconnect pump at infusion set
___ yes ___ no
Prepare reservoir and tubing
___ yes ___ no
Insert infusion set
___ yes ___ no
Troubleshoot alarms and malfunctions
___ yes ___ no
For Students Taking Oral Diabetes Medications
Type of medication: ______________________________________________ Time _________
Other medications: ______________________________________________ Time:_________
Blood Glucose Testing:
Will student require routine glucose monitoring at school? ___ yes ___ no
Will student require assistance with routine glucose monitoring? ___ yes ___ no
If so, please note what type of assistance is needed.____________________________________
Time of day blood glucose should be routinely checked:_________________________________
Type of glucometer:_____________________________________________________________
Does student check urine for glucose?
___ yes ___ no
Inspiring and Challenging
EVERY CHILD, EVERY DAY
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