Diabetes Care Plan Template Page 2
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1
2INSULIN ADMINISTRATION
Yes
No
Does the student require insulin to be given at school?
Yes
No
If Yes, is supervision required for the student?
Note: Supervision of insulin administration is recommended for all primary school students, to ensure the
prescribed dose of insulin is delivered and documented accurately.
(If Yes, please provide the following details)
Routine insulin administration times at school:
1………………………………………………………………………………………………………………………….
2………………………………………………………………………………………………………………………….
Note: A DECS medication authority is required if insulin is to be administered at school
MANAGING CHANGES IN ROUTINE (EXCURSIONS, SWIMMING, CAMPS)
Planning with parents well before the activity is important
The student will need to eat meals and snacks at the usual school times (may need special permission to eat on the bus)
The student may need to eat extra food if more active than usual
Additional supervision will be required for swimming and aquatics activities
Seek parents’ advice regarding appropriate foods for parties and celebrations
Early and careful planning with both parents and medical team is required prior to school camps, and a specific care plan
for camp may be required.
ADDITIONAL INFORMATION
………………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………………….
Additional information attached to this care plan
DECS Medication Authority
Individual blood glucose chart
Individual insulin dose chart
General information about this person’s condition
Additional individual care information
First Aid Flowcharts
Other (please specify)
Further Information
Diabetes Planning and Support Guide for Education and Childcare Services:
> A – Z Health Support
•
Index > diabetes
•
*
THIS PLAN HAS BEEN DEVELOPED FOR THE FOLLOWING SERVICES/SETTINGS
School/education
Outings/camps/holidays/aquatics
Child/care
Work
Respite/accommodation
Home
(please specify) _________________
Transport
Other
AUTHORISATION AND RELEASE
Medical Professional/Diabetes Educator
_______________ Professional role ________________
Address
Telephone
Signature
Date
I have read, understood and agreed w ith this plan and any attachm ents indicated above.
I approve the release of this inform ation to supervising staff and em ergency m edical personnel.
Parent/guardian
Signature
Date
Family name (please print)
First name (please print)
DECS Diabetes care plan 2009
Updated Dec 2010
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