Diabetes Medical Management Plan (Dmmp) Template
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7Diabetes Medical
Page 1 of 7, DMMP
Management Plan (DMMP)
This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. It should
be reviewed with relevant school staff and copies should be kept in a place that can be accessed easily by the school nurse,
trained diabetes personnel, and other authorized personnel.
Date of plan: _________________________
This plan is valid for the current school year: ___________–___________
Student information
Student’s name: ____________________________________________________ Date of birth: _________________________
Date of diabetes diagnosis: _________________________
Type 1
Type 2
Other: _________________________
School: _________________________________________ __________
School phone number: _________________________
Grade: _________________________ Homeroom teacher: ________ ____________________________________ ___________
School nurse: ___________________________________________________________
Phone: _________________________
Contact information
Parent/guardian 1: ____________________________________________________________________ _________________
Address: ________________________________________________________________________________ _______________
Telephone: Home: _________________________ Work: _________________________ Cell: _________________________
Email address: _________________________________________________________________________ __________________
Parent/guardian 2: ______________________________________________________________ ________________________
Address: ______________________________________________________________________________________ _________
Telephone: Home: _________________________ Work: _________________________ Cell: _________________________
Email address: _________________________________________________________________________ __________________
Student’s physician/health care provider: __________________________________________________________________
Address: ________________________________________________________________________ _______________________
Telephone: _____________________________________ Emergency number: _____________________________________
Email address: _________________________________________________________________________ ______ _____________
Other emergency contacts:
Name: __________________________________________ Relationship: __________________________________________
Telephone: Home: _________________________ Work: _________________________ Cell: _________________________
Page 1 of 7, DMMP
Tools for Effective Diabetes Management
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