Virginia School Diabetes Medical Management Forms

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III. Virginia School Diabetes Medical
Management Forms
Student ___________________________
School ____________________ Effective Date ____________
Date of Birth ________________ Grade __________ Homeroom Teacher _________________________
Dear Parent/Guardian:
1. Part 1- Medical history and contact information. To be completed by parent/guardian.
Includes: Parent authorization for trained school designees. To be completed by parent/guardian.
2. Part 2*- Have your child’s physician complete unless the physician’s office prefers to use his/her
own Diabetes Medical Management Plan. Please note that physician authorization for treatment
by trained school designees must be included in the Diabetes Medical Management Plan or a
separate form must be provided.
3. Part 3*- Have the physician/diabetes educator/caregiver complete if your child wears an insulin
pump.
4. Part 4- If your child is going to carry and self administer insulin and perform blood sugar checks in
the classroom; an “Authorization to Carry and Self-Administer Medication Form” must be
completed by the physician, school nurse and the parent.
*Other Diabetic Medical Management Plans may be used for Parts 2 & 3 as long as all components
are represented.
Return completed forms to the school nurse as quickly as possible. Thank you for your cooperation.
School nurse__________________________________ Phone_____________ Date____________
Please note: during the school year, in order to change your child’s diabetes care at school, an updated
physician’s order must be submitted to the school nurse.
Part 1: Parent/Guardian to complete:
Contact Information:
Parent/Guardian #1:__________________________________________________________________________
Address: _____________________________________________________________________________
Telephone-Home: _______________________Work: ________________ Cell: _____________________
Parent/Guardian #2:__________________________________________________________________________
Address: ____________________________________________________________________________
Telephone-Home: _______________________Work: ________________ Cell: _____________________
Other emergency contact: _____________________________________________________________________
Address: ___________________________________________ Relationship: _______________________
Telephone-Home: _______________________ Work: ________________ Cell: _____________________
Physician managing diabetes: __________________________________________________________________
Address: _____________________________________________________________________________
Main Office #_________________ Fax #_________________ Emergency Phone #___________________
Nurse/Diabetes Educator _______________________________________ Work # _______________________
Diabetes Questions
Parent/Guardian Response
(check appropriate boxes and complete blanks)
Diagnosis information
At what age?
Type of diabetes?
How often is child seen
by this physician?
Include date last seen.
Nutritional needs
Snack
____AM
____PM
_____Prior to Exercise/Activity
Only in case of low blood glucose
Student may determine if CHO counting

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