School Care Plan Diabetes PDF Details

As a teacher, when you have a student with diabetes in your care, you will need to complete a School Care Plan Diabetes Form. This form is designed to help ensure that the school has all of the information they need to provide appropriate care for the student while they are at school. The form can be completed by either the parents or the doctor, and it provides information on everything from how the student will manage their diabetes while at school to what type of supplies they will need. completing this form is an important step in ensuring that your student with diabetes has a safe and successful experience at school.

You could find it useful to understand the amount of time you'll need to prepare this school care plan diabetes and just how long the form is.

Form NameSchool Care Plan Diabetes
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesdiabetes management plan school, developing nursing care plan for type 1 diabetes in school setting, nursing care plan for diabetes mellitus, diabetes action plan for school

Form Preview Example



Student____________________DOB: ____________Grade/Teacher _________________________




Phone (H) - ________________(W)______

Cell# _______________


Emergency Contact/Phone ________________________ _____________________________


Diabetes Nurse Educator

Hospital of choice_______________________________________________________________

DIABETES: Type 1 diabetes is a chronic metabolic condition. Diabetes can be controlled with insulin, diet, and exercise. People with diabetes can be expected to participate in all activities and lead a normal, active life intellectually, socially, and physically. The most frequent complication of diabetes is low blood sugar or hypoglycemia. This can be caused by: inadequate intake of food, emotional stress, too much exercise, receiving too much insulin. The emergency response plan for hypoglycemia is attached.

Target Blood Sugar Range______________to_______________

BLOOD SUGAR CHECKS (Check all that apply):

____Student can perform checks independently or _____Staff must supervise blood sugar checks

Times to do blood sugar checks ____Before lunch, ____After lunch, ____Before PE, ____After PE,

___As needed for signs of low or high blood sugar, Other_________________________________

Place (in school) to check blood sugar____________________________________

Glucometer Type/Brand_________________________________________

Supplies/glucometer will be kept:



Student can give his/her own insulin? ____yes ____ (Responsible secondary students may administer their

own insulin provided the school has Dr.’s order and authorization. Otherwise, a parent will need to come to the school to administer the insulin since this cannot be delegated to school staff.)

Insulin administered by (check): ____pen ____syringe ____insulin pump

Type of insulin ____Humalog ____Novolog ____Regular

Time(s) insulin to be given:_________________________________________________________________

Student calculates Insulin/Carb Ratio ____yes



___Unit for every ____grams of carbohydrate eaten


Student calculates correction dose _____yes



_____unit(s) for every ___mg/dl points above _____mg/dl


Student has pump that calculates correction dose and insulin/carb ratio? _____yes


Other medications/allergies_______________________________________________








Lunch time_______________



Physical Education is scheduled at ___________am/pm, Days M T W Th F


Snack: _____is not necessary before PE.


Snack times____________________ Will student need to be reminded? _n/a___yes


Preferred snacks/parent instruction for class parties : Call







FIELD TRIPS: Extra snacks, glucose monitoring kit, copy of health plan, glucose gel or other emergency supplies must accompany student on field trip.




Notify parent if child’s blood sugar is below__________or above__________mg/dl.


Student to be treated when blood sugar is below ____________________________________

MILD LOW BLOOD SUGAR Signs/Symptoms may include hunger, irritability, shakiness, sleepiness, sweating, pallor, uncooperative, crying or other behavioral changes. Additional student symptoms_______________________________________________________________________


Never leave student unattended. If treated outside the classroom, a responsible person must accompany student to health office.

Give juice (1 carton), or regular pop (1 cup), or 2-3 glucose tabs; (1 small tube of cake decorating gel can also be placed between cheek and gum with head elevated)

Wait 10-15 minutes. Recheck blood sugar. Retreat as above if still below 75, or if symptoms persist.

When symptoms improve or blood sugar is >75, give substantial snack (carbohydrate and protein) or lunch.



Signs/Symptoms: Seizure or loss of consciousness or student unwilling/unable to take gel or juice. Treatment:

CALL 911

- Stay with student

Place student on side

- Do not put anything in mouth



Student must be treated when blood sugar is above ___________.

Signs/Symptoms may include: extreme thirst, headache, abdominal pain, nausea, increased urination Treatment:

-Drink 6-8 ounces of water every hour. Allow student to carry water bottle with them.

-Use restroom as needed.

-Do not allow exercise.

-Student to administer insulin if ordered by health care provider

-For pumps, will student be able to change infusion set, or have an alternate source of insulin at school?________________________________________________________________________

-If student exhibits nausea, vomiting, stomachache or is lethargic, notify parents and school nurse ASAP.

-Send student back to class if none of the above symptoms are present.


I understand that all monitoring equipment, snacks, glucose are to be provided by the family. In case of an emergency, contact the 911 emergency response team for further evaluation.

If parents are unavailable, the physician or diabetic nurse educator may be contacted for specific information. If transportation by ambulance is necessary, parents will assume responsibility for payment.

Parent(s) Signature:______________________________________ Date:_________________

Nurse Signature:________________________________________ Date:_________________


How to Edit School Care Plan Diabetes Online for Free

Our PDF editor can make writing files convenient. It is extremely convenient to update the [FORMNAME] document. Keep up with these particular actions if you want to do it:

Step 1: Click the "Get Form Here" button.

Step 2: So, you are able to update the diabetic school health care plan. Our multifunctional toolbar allows you to insert, get rid of, adapt, highlight, as well as carry out similar commands to the words and phrases and areas inside the document.

You should provide the following details to fill out the diabetic school health care plan PDF:

diabetes action plan for school empty spaces to fill out

Write down the demanded data in the field BLOOD SUGAR CHECKS Check all that, MEDICATIONS TO BE GIVEN DURING, Unit for every grams of, Student calculates correction dose, units for every mgdl points above, Student has pump that calculates, DIET Lunch time Physical Education, Snack is not necessary before PE, and Snack times Will student need to.

diabetes action plan for school BLOOD SUGAR CHECKS Check all that, MEDICATIONS TO BE GIVEN DURING, Unit for every grams of, Student calculates correction dose, units for every mgdl points above, Student has pump that calculates, DIET Lunch time Physical Education, Snack is not necessary before PE, and Snack times Will student need to blanks to complete

You should include some data inside the section EMERGENCY RESPONSE PLAN DIABETES, StudentDOBGradeTeacher, Notify parent if childs blood, HYPOGLYCEMIA INSULIN REACTION LOW, MILD LOW BLOOD SUGAR SignsSymptoms, Treatment, Never leave student unattended If, accompany student to health office, Give juice carton or regular pop, decorating gel can also be placed, Wait minutes Recheck blood sugar, persist, When symptoms improve or blood, protein or lunch, and Comments.

stage 3 to finishing diabetes action plan for school

The space CALL Place student on side, Stay with student Do not put, Comments, HYPERGLYCEMIA HIGH BLOOD SUGAR, and I understand that all monitoring is going to be where you can include both parties' rights and responsibilities.

diabetes action plan for school CALL  Place student on side, Stay with student  Do not put, Comments, HYPERGLYCEMIA  HIGH BLOOD SUGAR, and I understand that all monitoring blanks to insert

End by looking at the following areas and submitting the relevant data: I understand that all monitoring, Parents Signature Date, Nurse Signature Date, and Confidential.

Completing diabetes action plan for school stage 5

Step 3: When you are done, click the "Done" button to transfer the PDF form.

Step 4: Be sure to stay clear of possible future misunderstandings by getting a minimum of 2 copies of your form.

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