CENTENNIAL SCHOOL DISTRICT
DIABETES MEDICAL MANAGEMENT PLAN

Effective Date: ________________________________Today's Date: ___________________________________

This plan should be completed by the students personal medical doctor and parent/guardian. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the School Nurse and other authorized personnel. 

Student's Name: _______________________________________________________________________________ 

Date of Birth: _______________________________Date of Diabetes Diagnosis: ___________________________
 
School: ______________________________________________________________________________________

Grade: ___________________ Homeroom Teacher/Team______________________________________________

Physical Condition: Diabetes Type 1____________     Diabetes Type 2___________

Contact Information:

Mother/Guardian: 

Address: ____________________________________________________________________________

Telephone: Home: _________________________Work: _____________________Cell:__________________ 

Father/Guardian: ____________________________________________________________________

Address: ____________________________________________________________________________

Telephone: Home: _____________________	Work: ______________________Cell:__________________ 

Student's Doctor/Health Care Provider: 

Name: __________________________________ Telephone: ___________________________________

Address:________________________________Emergency Number: ____________________________

Other Emergency Contacts: 

Name: ______________________________________________________________________________________

Relationship: _______________________________

Telephone: Home: ________________Work: ____________________Cell:__________________________ 

Diabetes Medical Management Plan Continued 

Blood Glucose Monitoring 
Target range for blood glucose is:   ⁯70-150       ⁯70-180        ⁯Other_______________________ 
Usual times to check blood glucose___________________________________________________ 
Times to do extra blood glucose checks (check all that apply)
⁭ before exercise 
⁭ after exercise 
⁭ when student exhibits symptoms of hyperglycemia 
⁭ when student exhibits symptoms of hypoglycemia 
⁭ other {explain): ______________________________________ 
Can student perform own blood glucose checks?     ⁭ Yes ⁭ No
Exceptions: ________________________________________________________________________ 
Type of blood glucose meter student uses: ________________________________________________
 
Insulin 

Usual Lunchtime Dose 

Base dose of Humalog/Novolog /Regular insulin at lunch (circle type of rapid-/short-acting insulin used) is 
_____ units or does flexible dosing using ______units/ ________ grams carbohydrate. 

Use of other insulin at lunch: (circle type of insulin used): intermediate/NPH/lente _______ units or 
Basal/Lantus/Ultralente ______units. 

Insulin Correction Doses 
Parental authorization should be obtained before administering a correction dose for high blood glucose levels. ⁭ Yes ⁭ No 
_________ units if blood g1ucose is _______ to _______ mg/dl
_________ units if blood g1ucose is _______ to _______ mg/dl
_________ units if blood g1ucose is _______ to _______ mg/dl
_________ units if blood g1ucose is _______ to _______ mg/dl
_________ units if blood g1ucose is _______ to _______ mg/dl

Can student give own injections?    ⁭ Yes  ⁭ No 
Can student determine correct amount of insulin?  ⁭Yes  ⁭ No 
Can student draw correct dose of insulin?   ⁭Yes ⁭No 
Parents are authorized to adjust the insulin dosage under the following circumstances:_____________________
__________________________________________________________________________________________

For Students With Insulin Pumps 

Type of pump: ______________________________________Basal rates: _______ 12 am to _______ 
                                                                                                                         _______ _____ to _____ 
                                                                                                                         _______ _____ to _____ 
Type of insulin in pump: _____________________________________________________________________
Type of infusion set: ________________________________________________________________________
Insulin/carbohydrate ratio: ______________________Correction factor: _______________________________

Diabetes Medical Management Plan Continued 

Student Pump Abilities/Skills: 
                                                                                                 Needs Assisstance?
Count carbohydrates                                                                      ⁭Yes  ⁭No  
Bolus correct amount for carbohydrates consumed                       ⁭Yes  ⁭No  
Calculate and administer corrective bolus                                     ⁭Yes  ⁭No  
Calculate and set basal profiles                                                      ⁭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  

For Students Taking Oral Diabetes Medications 

Type of medication:_________________________________________Timing:__________________________
Other medications: __________________________________________Timing:__________________________

Meals and Snacks Eaten at School 

Is student independent in carbohydrate calculations and management?   ⁭ Yes  ⁭  No 
Meal/Snack                                                Time                                              Food Content/Amount
Breakfast                            __________________________                __________________________  
Mid-morning snack.          __________________________                 __________________________
Lunch                                 __________________________                 __________________________
Mid-afternoon snack          __________________________                 __________________________
Dinner                                __________________________                 __________________________
Snack before exercise?   ⁭Yes   ⁭No 
Snack after exercise?      ⁭Yes   ⁭No 
Other times to give snacks and content/amount:____________________________________________________
Preferred snack foods:________________________________________________________________________ 
Foods to avoid, if any:________________________________________________________________________ 
Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event): ____________________________________________________________________________________________________________________________________________________________________________________

Exercise and Sports 

A fast-acting carbohydrate such as ______________________________________________________should be 
available at the site of exercise or sports. 

Restrictions on activity, if any:_________________________________________________________________ 
__________________________________________________________________________________________

Student should not exercise if blood glucose level is below ___________mg/dl or above ____________ mgldl 
or if moderate to large urine ketones are present. 
Diabetes Medical Management Plan Continued 

Hypoglycemia (Low Blood Sugar) 

Usual symptoms of hypoglycemia:_____________________________________________________________
__________________________________________________________________________________________
Treatment of hypoglycemia:___________________________________________________________________
__________________________________________________________________________________________ 
Glucagon should be given if the student is unconscious, having a seizure (convulsion), or unable to swallow. 
Route_______________Dosage__________Site for glucagon injection:____arm,___thigh,____other. 
If glucagon is required, administer it promptly. Then, call 911 (or other emergency assistance) and the parents or guardian. 

Hyperglycemia (High Blood Sugar) 

Usual symptoms of hyperglycemia: _____________________________________________________________
__________________________________________________________________________________________ 
Treatment of hyperglycemia:__________________________________________________________________
__________________________________________________________________________________________
Urine should be checked for ketones when blood glucose levels are above ___________mg/dl. 
Treatment for ketones: _______________________________________________________________________ 

Supplies to be Kept at School 

_____ Blood glucose meter, blood glucose test 
           strips, batteries for meter 
_____ Lancet device, lancets, gloves, etc.
_____Urine ketone strips 
_____ Insulin vials and syringes 

_____ Insulin pump and supplies 
_____ Insulin pen, pen needles, insulin cartridges
_____ Fast-acting source· of glucose 
_____ Carbohydrate containing snack 
_____Glucagon emergency kit 

Signatures 

This Diabetes Medical Management Plan has been approved by: 
______________________________________________________          _____________________________
	Student's Physician/Health Care Provider                                                      	Date 
I give permission to the school nurse, trained diabetes personnel, and other designated staff members of _____________________________________ school to perform and carry out the diabetes care tasks as outlined by __________________________________ 's Diabetes Medical Management Plan. I also consent to the release of the information contained in this Diabetes Medical Management Plan to all staff members and other adults who have custodial care of my child and who may need to know this information to maintain my child's health and safety. 

Acknowledged and received by: 

_____________________________________________________                _______________________       
                         Student’s Parent/Guardian                                                                       Date

_____________________________________________________                _______________________       
                         Student’s Parent/Guardian                                                                       Date