Student Diabetes Injection/Pump Careplan for School

Student Diabetes Injection/Pump Careplan for School
INDIVIDUALIZED HEALTHCARE PLAN – DIABETES WITH INJECTION
HEALTHCARE PROVIDER ORDERS
EFFECTIVE DATE:
STUDENT’S NAME:
End Date:
Date of Birth:
DIABETES HEALTHCARE PROVIDER INFORMATION
Phone #:
Name:
Fax #:
Email
SCHOOL:
School Fax:
Monitor Blood Glucose – test ...
 If student has symptoms of high or, without moving student, low blood glucose
STUDENTS WITH DIABETES TREATED BY INJECTION



Before breakfast
 After lunch
 Before exercise/PE
Before mid-morning snack
 Before afternoon snack
 After exercise/PE
Before lunch
 Before leaving school
 Other:
Where to test:
 Classroom
 Health office
 Other: _______________
 Without moving student if has low blood glucose symptoms
Routine Daily Insulin Injection:
Correction insulin dose for high blood glucose:
Insulin Delivery:
Time to be given:  Before lunch ONLY
 Use correction scale
 Syringe/vial
 Pen
Type:  rapid acting (Humalog / NovoLog /
Apidra)  regular or  other: _____________

Blood glucose range
mg/dl
Give ____ unit(s) of rapid-acting insulin
mg/dl
for ___ grams of carbohydrate.
mg/dl
Type
Dose
Time
Check ketones if nausea,
vomiting or abdominal pain
OR if blood glucose >300
twice when tested 3 hours
apart.
 Give ____ units of rapidacting insulin for
moderate and ____ units
for large ketones.
mg/dl
 breakfast  AM snack
 lunch  PM snack  parties.
OR
 Standard daily insulin injection:
Insulin units
mg/dl
Calculate insulin dose for carbohydrate
intake:
Give at:
 Other: ___________________
mg/dl
mg/dl
 Use Formula to calculate correction dose
 Repeat ketone test in 2
hours, and repeat
additional insulin if
moderate or large
ketones are still present.
(Blood glucose- _____ ÷ _____) =
_____ units of insulin.
 Carbohydrate coverage and pre-meal
correction doses may be combined.
 If BG <70 before a meal treat with carbohydrate OR subtract _ unit insulin.
Do not give insulin correction dose more than once every 2 to 3 hours.
Exercise and Sports
 Student should monitor blood glucose hourly.
Parent/Guardian Authority to Adjust Insulin Dose
Dose adjustment allowed up to 20% higher or lower  Yes
 No
Other Health Concerns and Medications
Other health concerns:



Allergies:
Glucagon
Dose: _____________
IM or SC per thigh or arm
Oral diabetes medication(s)/dose: ________________________________ Times to be given: _____________________
Other medication(s)/dose: ______________________________________ Times to be given: _____________________
___________________________________________________________ Times to be given: _____________________
HCP Assessment of Student’s Diabetes Management Skills:
Skill
Independent
Needs supervision
Note
Cannot do
Check blood glucose
Count carbohydrates
Calculate insulin dose
Injection
HEALTHCARE PROVIDER
SIGNATURE/STAMP:
Date:
UPDATED
Date
Change
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
Initials
Revised 5/28/2013
INDIVIDUALIZED HEALTHCARE PLAN – DIABETES WITH PUMP
HEALTHCARE PROVIDER ORDERS
EFFECTIVE DATE:
STUDENT’S NAME:
End Date:
Date of Birth:
DIABETES HEALTHCARE PROVIDER INFORMATION
Phone #:
Name:
Fax #:
Email
SCHOOL:
School Fax:
Monitor Blood Glucose – test ...
 If student has symptoms of high or low blood glucose




Before breakfast
Before mid-morning snack
Before lunch
All test results should be entered into pump
Where to test:
 After lunch
 Before afternoon snack
 Before leaving school
to determine need for bolus correction.
Before exercise/PE
After exercise/PE
Other:
 Classroom
 Health office
 Other: _______________
 Without moving student if has low blood glucose symptoms
Insulin Pump Information
STUDENTS WITH DIABETES TREATED BY PUMP



 Humalog or NovoLog or Apidra by pump
Basal rates during school: ____________________________________
_____________________________________
 Place pump on suspend when blood glucose is less than ____mg/dl and re-activate it when blood glucose is at least _____
mg/dl.
Pump settings should not be changed by school staff.
Carbohydrate Bolus
Correction Bolus for Hyperglycemia
Time to be given:
Give 1 unit of insulin per
gm carbohydrate at breakfast
gm carbohydrate at AM snack
gm carbohydrate at lunch
gm carbohydrate at PM snack
Bolus should occur:
 before eating, or
 other:
_____________________________________

 Before lunch ONLY  Other: ______________
Give ___ units of insulin for each ____mg/dl of blood glucose with a target
blood glucose of _____mg/dl.
Check ketones if nausea, vomiting or abdominal pain OR if blood glucose
>300 twice when tested 3 hours apart.
o Via syringe, give ____ units for moderate and ___ units of rapidacting insulin for large ketones. Repeat blood glucose test in 2 hours,
and repeat additional insulin if moderate or large ketones are still
present.
 If BG <70 before a meal treat with carbohydrate OR subtract _ unit insulin.
Do not give correction dose of insulin more than once every 2 to 3
hours.

If infusion set comes out or needs to be changed:  Change set at school  Insulin via syringe every 3 hours
Exercise and Sports with Pump
Temporary Basal Decrease:  No  Yes (___% or ____ units for _____ minutes or  duration of exercise)
 Student should monitor blood glucose hourly.
HCP Assessment of Student’s Diabetes Management Skills:
Skill
Independent
Needs supervision
Note
Cannot do
Check blood glucose
Count carbohydrates
Calculate insulin dose
Change infusion set
Injection
Trouble shoot alarms, malfunctions
Notes:
Parent/Guardian Authority to Adjust Insulin Dose
Dose adjustment allowed up to 20% higher or lower  Yes
Other health concerns:



 No
Allergies:
Glucagon
Dose: _____________
IM or SC per thigh or arm
Oral diabetes medication(s)/dose: ________________________________ Times to be given: _____________________
Other medication(s)/dose: ______________________________________ Times to be given: _____________________
HEALTHCARE PROVIDER
SIGNATURE/STAMP:
Date:
UPDATED
Date
Change
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
Initials
Revised 5/28/2013
STUDENT’S NAME:
Student’s usual LOW
_ Shaky or jittery
_ Sweaty
_ Hungry
_ Pale
_ Headache
_ Blurry vision
_ Sleepy
_ Dizzy
blood glucose symptoms:
_ Uncoordinated
_ Irritable, nervous
_ Argumentative
_ Combative
_ Changed personality
_ Changed behavior
_ Unable to concentrate
_ Weak, lethargic
ALGORITHMS FOR BLOOD GLUCOSE RESULTS
BELOW 70
1. Give 15 gm fast-acting
carbohydrate
2. Observe for 15 minutes
3. Retest blood glucose.
a. If less than 70, repeat 15 gm
carbohydrate.
b. If over 70, give carbohydrate
and protein snack (e.g.,
crackers and cheese) if not
eating a meal within an hour.
4. Notify school nurse and parent if
no improvement
5. Student should not exercise
CALL 911 if student becomes
unconscious, seizures or is
unable to swallow
o Turn student on side to ensure open
airway
o Give glucagon as ordered. Keep
student in recovery position on side.
o If on insulin pump, either place it in
‘suspend’ or stop mode, disconnect it
at the pigtail or clip, or cut tubing. If
pump was removed, send it with
EMS to the hospital.
o Notify school nurse, parent and HCP
o Wait 15 minutes; if no response,
repeat glucagon.
o If responsive, offer juice. Wait 15
minutes and give protein &
carbohydrate snack.
CHECK BLOOD GLUCOSE
70 – 90
1. Give 15 gm carbohydrate.
a. If meal or snack is within
30 minutes, no additional
carbs are needed.
or
b. If student is not going to
eat within 30 minutes, give
carbohydrate and protein
snack.
Student may eat
before exercising
or recess.
If student’s blood glucose
result is immediately following
strenuous activity, give 15 gm
carbohydrate snack.
15 GM FAST-ACTING CARBOHYDRATE =
 ½ c. juice
 3-4 glucose tablets
 Tube of glucose gel
 ½ c. regular (not diet) soda
 6-7 small sugar candies (to
chew)
 1 c. skim milk
Do not give chocolate
126-300
ABOVE 300
No action
needed.
STUDENT TREATED BY PUMP
STUDENT TREATED BY
INJECTION
1. Use correction scale or
formula at lunch or every 23 hours
2. Check ketones if symptoms
or if blood glucose>300
twice in a row:
a. If ketones are absent or
small, encourage exercise
and water
b. If ketones moderate or
large:
 No exercise; give water
 Add units of insulin per
orders
3. Notify school nurse and
parent
4. Provide free,
unrestricted access to
water and the restroom.
1. If 2-3 hours since last bolus, treat with
correction bolus via pump. Re-check in
2- 3 hrs. Trouble shoot pump function.
 Check for redness at site, tubing for
kinks or air bubble, insulin supply
2. If blood glucose still ≥ 300 mg/dl and
not explained, check ketones:
a. If ketones are absent or small,
encourage exercise and water
b. If ketones moderate or large:
 Give insulin correction dose per
orders via syringe.
 No exercise; encourage water
3. Change infusion set or continue insulin
injections every 2-3 hours via syringe.
4. Notify school nurse and parent
5. Provide free, unrestricted access to
water and the restroom.
CALL 911 if the student
vomits, becomes lethargic
and/or has labored breathing.
Notify school nurse, parent and HCP.
EXERCISE AND SPORTS
 Assure has quick access to water for hydration, fast-acting carbohydrates, snacks and monitoring equipment.
 Student should not exercise if blood glucose level is below 70 mg/dl or if has moderate to large ketones.
*Never send a child with suspected low blood glucose anywhere alone.*
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
91-125
Student’s usual HIGH blood glucose symptoms:
Hyperglycemia
Emergency levels
_ Increased thirst, dry
_ Extreme thirst
mouth
_ Nausea, vomiting
_ Frequent or increased
_ Severe abdominal
urination
pain
_ Change in appetite,
_ Fruity breath
nausea
_ Heavy breathing,
_ Blurry vision
shortness of breath
_ Fatigue
_ Increasing sleepiness,
_ Other
lethargy
2
Revised 5/28/2013
INDIVIDUALIZED HEALTHCARE PLAN - DIABETES
SCHOOL AND PARENT PART
STUDENT’S NAME:
Diabetes information
 Diabetes Type 1
PLAN EFFECTIVE
DATE:
Date of Diagnosis:
 Diabetes Type 2
Student’s photo
 Other
SCHOOL INFORMATION
Grade:
504 plan on file:
Teacher:
 Yes  No
CONTACT INFORMATION:
Name
Parent/Guardian 1:
Phone numbers:
Home
Parent/Guardian 2:
Phone numbers:
Phone numbers:
Work
Cell
Other
Name
Home
Other/emergency:
Call first 
Call first 
Work
Cell
Other
Name:
Home
Relationship:
Work
Additional Times to Contact Parent...
Cell
Other
Student treated by pump:
 Blood Glucose test out of target range
 Carbohydrate bolus
 Correction bolus
 Infusion set comes out/needs to be replaced
Student treated by injection
 Blood Glucose test out of target range
 Routine Daily Insulin injections
 Correction dose
STUDENT DIABETES SELF-MANAGEMENT PLAN
Student will manage diabetes
independently

Trained staff will supervise student self-care
 Verify blood glucose test
 Check carbohydrate count
 Confirm dose
 Supervise insulin self-injection
 Monitor bolus administration
 Trouble shoot pump alarms, malfunction
 Watch infusion set change
Student has signed
Agreement for Student
Independently Managing
Diabetes
FOOD PLAN
Time
Notes
Trained staff will provide care
 Test blood glucose
 Count carbohydrates
 Calculate insulin dose and inject as above
 Provide insulin injection
 Administer bolus
 Trouble shoot pump alarms, malfunction
 Change infusion set
Monitor/Remind Student
Food at a classroom/school party:
Yes

Student will eat treat

Replace the treat with a parent-supplied
alternative
Lunch

Put in baggie to take home with teacher note
Afternoon snack

Student should not eat treat
Extra snack Before exercise

Modify the treat as follows:
No
Breakfast
Morning snack
After exercise
BUS TRANSPORTATION PLAN
Bus transportation:


 To school
 Home

Test blood 10-20 minutes before boarding school bus home. Student must have blood glucose >
70 mg/dl to board bus; if ≤ 70, provide care based on algorithm and call to have student picked up.
Blood test not required.
Student may test
blood glucose and
self-manage
diabetes while on
the bus.
FIELD TRIPS
 School nurse to be notified two weeks before the field trip to assure qualified personnel are available.


All diabetes supplies are taken and care is provided according to this Plan (copy to accompany trip).
Lunch and snack times should not change.
SCHEDULED AFTER- OR BEFORE-SCHOOL ACTIVITIES
List of clubs, sports, etc. that student anticipates:
If parent wants trained staff coverage for an activity, parent will notify school nurse two weeks before it begins
ADDITIONAL NOTES
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
3
Revised 5/28/2013
STUDENT’S NAME:
PLAN EFFECTIVE DATE:
 Means student uses this item AND parent will provide.
 Blood Glucose Test Kit



Meter
Test strips
Lancing device and lancet


Sharps container
Anti-bacterial
cleaner/alcohol swabs
cotton balls
spot band-aids


Glucose meter brand/model:
 Insulin
Treatment by Injection
 Insulin pen
 Pre-filled syringes (labeled
per dose)
 Insulin vials and syringes
Treatment by Pump
 Pump syringe
 Pump tubing/needle
 Batteries
 Tape


Sof-serter
Insulin vial and
syringes
Infusion set type:
__________________
SUPPLY LIST
Pump type
 Medtronic MiniMed
www.minimed.com
(800) 826-2099
 Animas
www.animas.com
(877) 767-7373
 Omnipod
www.myomnipod.com
(800) 591-3455
 Low Blood Glucose (5-day supply)



Fast-acting carbohydrate drink (apple juice, orange juice, regular soda pop – NOT diet), ≥ 6 containers
Pre-packaged snacks (e.g., crackers with cheese or peanut butter, nite bite), ≥ 5 servings
Supply of fast-acting glucose at least equal to 15 gm per day for 5 days (e.g., ≥ 75 gm total)
 Glucagon Kit
 High Blood Glucose

Urine ketone test strips/bottle
 Urine cup
 Water bottle
(Timing device may be wall clock or watch)
 3-day Disaster Kit





Complete daily insulin dose schedule (separate page)
Blood glucose test kit (testing strips, lancing device, lancets, meter batteries)
Vial of insulin and 6 syringes; insulin pens and supplies
Insulin pump and pump supplies
Hypoglycemia treatment supplies, ≥ 3 episodes





Other medications, including glucagon kit
Urine ketone strips/plastic cup
Antiseptic wipes or hand sanitizer
3-day food supply with meal plan
Other:
SUPPLY LOCATIONS
 Other
With
student
In
classroom
In health
office
Other
With
student
Daily breakfast,
snacks and lunch
Blood glucose test kit
Extra kit
Extra snacks
Pump supplies
Low blood glucose
supplies
Insulin
Daily use
Extra/emergency
High blood glucose
supplies
Disaster
Disaster food
In
classroom
In health
office
Other
Other
SIGNATURES
As parent/guardian of the above-named student, I give permission for the school nurse and/or other trained staff of
__________________________ to perform and carry out the diabetes care tasks as outlined in this Individualized Healthcare Plan.
(school)
o
o
o
o
o
I have reviewed this plan and agree with the indicated instructions. I understand that the school is not responsible for equipment
loss or damage, or expenses associated with these treatments and procedures.
I understand that the information contained in this plan will be shared with other school staff on a need-to-know basis.
I give permission to the school nurse to contact my child’s physician/health care provider and discuss my child’s care related to
this plan.
I will notify the school nurse whenever there is any change in my child’s health status or care.
My child and I are responsible for maintaining the necessary supplies, snacks, blood glucose meter, medications and other
equipment.
________________________________________________ ______________________________________________________
Student’s parent/guardian
Date
Student’s parent/guardian
Date
________________________________________________
School nurse
Date
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
4
Revised 5/28/2013
AGREEMENT FOR STUDENTS INDEPENDENTLY MANAGING THEIR DIABETES
Student: _________________________________________
Student
Grade: _____
I agree to dispose of any sharps either by keeping them in my kit and taking them home, or placing them in
the sharps container provided at school.
 If so indicated in my Individualized Healthcare Plan, I will notify the health office if my blood sugar is
below _____ mg/dl or above ______ mg/dl.
 I will not allow any other person to use my diabetes supplies.
 I plan to keep my diabetes supplies:
 With me
 In the school health office
 In an accessible and secure location (_________________________)
 I will seek help in managing my diabetes from __________________________ if I need it.
 I understand that the freedom to manage my diabetes independently is a privilege and I agree to abide by
this contract.
Student’s signature: _____________________________________ Date: _________________

Parent/Guardian
I agree that my child can self-manage his/her diabetes and can recognize when he/she needs to seek help
from a staff member.
 I authorize my child to carry and self-administer diabetes medications and management supplies and I agree
to release the school district and school personnel from all claims of liability if my child suffers any adverse
reactions from self-management or storage of diabetes medications and blood glucose management
products.
 I will provide back-up supplies to the health office for emergencies.
 I understand that this contract is in effect for the current school year unless revoked by my son/daughter’s
physician or my son/daughter fails to meet the above safety guidelines.
Parent’s signature: ______________________________________ Date: _________________

School nurse
I will assure that school staff members that have the need to know about the student’s condition and the
need to carry their diabetes supplies with them have been notified.
School Nurse’s signature: _________________________________
Date: _________________

Based on a form posted on the Colorado Kids with Diabetes website (http://www.coloradokidswithdiabetes.org/index.php/NurseFiles.html)
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
5
Revised 5/28/2013
INDIVIDUALIZED HEALTHCARE PLAN - DIABETES
SCHOOL NURSE AND PARENT-AUTHORIZED TRAINED STAFF COVERAGE WORKSHEET
School nurse will be on-site
Mon
Tue
Wed
Thurs
Fri
Notes/comments:
First period
Second period
Third period
Fourth period
Fifth period
Sixth period
Seventh period
Field Trip
Before school starting __ AM
After school ending __ PM
Other
Schedule for Parent-Authorized Trained Staff
Staff person’s Name
Day(s) responsible
Time(s) responsible
Contact phone
 M  T  W  Th  F
From:
or Period:
To:
 M  T  W  Th  F
From:
or Period:
To:
 M  T  W  Th  F
From:
or Period:
To:
 M  T  W  Th  F
From:
or Period:
To:
 M  T  W  Th  F
From:
or Period:
To:
 M  T  W  Th  F
From:
or Period:
To:
 M  T  W  Th  F
From:
or Period:
To:
 M  T  W  Th  F
Before school starting ____AM
 M  T  W  Th  F
After school ending ______PM
Field trip
Other
Other
Attach if needed
 Delegation training completion
 Parent delegation authorization
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
6
Revised 5/28/2013
ALASKA INDIVIDUALIZED HEALTHCARE PLAN – DIABETES
WITH INJECTION OR WITH PUMP
Instructions
Purposes:
This healthcare plan is for all students with diabetes that monitor blood glucose at school and/or are on insulin or other
hypoglycemic medication and/or have a glucagon prescription.
1. Healthcare providers should use it to prescribe a particular treatment regimen including medication(s) for school
(HEALTHCARE PROVIDER ORDERS pages)
a. It documents the ability level of the student to self-manage their diabetes.
b. It provides the medical parameters for management of an individual student’s diabetes in the school setting.
2. It describes the standard of care for school staff to follow based on blood glucose test results and is the Emergency
Care Plan for students with diabetes. (ALGORITHMS FOR BLOOD GLUCOSE RESULTS page) NOTE: The standard of care
represents the care to follow in most cases; any individualization of clinical care for the student will be reflected in
the HEALTHCARE PROVIDER ORDERS.
3. School nurses and parents should use it to plan and implement individualized health interventions in the school
setting, based on the Healthcare Provider Orders page. (SCHOOL AND PARENT PART pages)
a. To support quality assurance of school health services.
b. To document parental wishes for diabetes management-related contact by school staff.
c. To document diabetes supplies needed at school, their locations and parental responsibility for maintaining
certain supplies at school.
d. To facilitate a safe process for the delegation of diabetes-management tasks to trained unlicensed school staff,
as needed.
4. School nurses and parents may use it to identify times when the school nurse will not be available to provide
diabetes management assistance and plan for coverage by trained school staff. (SCHOOL NURSE AND PARENT-AUTHORIZED
TRAINED STAFF COVERAGE WORKSHEET)
While current, this form should be kept in the school health office or with the staff member who is assisting with the
health management of the student.
Process:
1. Healthcare provider completes either the WITH INJECTION or the WITH PUMP page of the form to describe anticipated
medications/treatment needs for the entire school year, and sends it to the school nurse (if known) and/or the
student’s parent to brings into the school.
a. If medications and/or treatment change during the school year, a new form should be completed. Fax only the
page with new orders to the school.
b. Most categories are self-explanatory. On either form, check all boxes that apply and add information as
appropriate.
DIABETES WITH INJECTION notes:
 In the Routine Daily Insulin Injection box, there are three options for Type. NPH and Lantis are examples of
“other.” The relevant doses/times for these injections would be listed in the “Standard daily insulin
injection” table.
 Instructions in the Correction insulin dose for high blood glucose box are for a routine day as correction
dosing is generally given at mealtime, which means that:
o Action directed by the algorithm page supersedes “before lunch only” when it is checked
because it is based on the student’s symptoms and blood glucose levels.
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
7
Revised 5/28/2013
o

The “Do not give insulin correction dosing more often than every 2 to 3 hours” statement
applies to symptomatic treatment based on blood glucose levels in most instances.
In the Parent/Guardian Authority to Adjust Insulin Dose box, parental authority to adjust the dose up to 20%
higher or lower allows the parent to recommend dose adjustments to the nurse which the nurse could
follow without contacting the health care provider if the dose is within 20% of the range ordered by the
provider. If the dose recommended by the parent falls outside of the range, either higher or lower, the
nurse would need to contact the health care provider to verify the dose.
c. Healthcare provider signs and dates the WITH INJECTION or WITH PUMP page and faxes or sends the orders to the
school.
2. While meeting with the school nurse, the parent uses the boxes at the top of the ALGORITHMS page to indicate which
of the symptoms of low and high blood sugar generally occur for their child.
3. Together, the school nurse, parent and the student, if student is self-managing his/her diabetes, complete the
SCHOOL AND PARENT PART of the form.
a. Most categories are self-explanatory. Check all boxes that apply and add information as appropriate.
 In the Student Diabetes Self-Management Plan box:
o The repeated skills list (from the healthcare provider section) allows parent input and school nurse
assessment of the student skill level and the level of supervision or assistance needed. If the student
skill level increases during the school year, this section allows the school nurse and parent to adjust the
self-management plan accordingly.
o “Trained staff” (right-side column) in this instance includes the school nurse.
o For “Change infusion set” under “Trained staff will provide care”, the school nurse is typically the only
trained staff changing the infusion set for a student on a pump. Add this comment when needed.
 The SUPPLY LIST is intended to promote best practice. Generally, it should be interpreted by the nurse and
the parent as a guide.
 If the parent is unable to provide urine ketone test strips, contact the American Diabetes Association (907
272-1424). They will send some.
b. Parents and School Nurse sign and date the SCHOOL AND PARENT PART. If student will be self-managing, student
signs the STUDENT SELF-MANAGEMENT AGREEMENT.
c. Update as needed and/or on a yearly basis.
4. The school nurse may use the WORKSHEET page to identify times when he/she will regularly be unavailable to assist
the student with diabetes management and plan for coverage by trained school staff.
5. File the entire document with student’s health record at the end of the year or upon student withdrawal.
Created by the Alaska Division of Public Health and the American Diabetes Association, Alaska Area
NUR# 0541 (replaces forms NUR# 0513 & 0514)
8
Revised 5/28/2013
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