Diabetes Medical Management Plan
This form must be completed by the student’s physician or advanced practice nurse
and provides the medical “orders for the student’s care”. This section must be
signed and dated by the medical practitioner. This information will be used in the
development of the IHP and the IEHP. Please return it to the school nurse as soon as
possible. If you have any questions, the nurse can be reached at 973-764-2879.
Student’s Name: _____________________________________________________________
Effective Dates of Plan: _____________________________________________________
Physical Condition:
☐ Diabetes type I
☐ Diabetes type 2
1. 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 a student exhibits symptoms of hypoglycemia
☐ Other
(explain): _____________________________________________________________________________________
Can student perform own blood glucose checks?
Yes
No
Exceptions: ___________________________________________________________________________________
Type of blood glucose meter used by the student:
_________________________________________________________________________________________________
2. 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.
3. Insulin Correction Doses
Authorization from the student’s physician or advanced practice nurse MUST be
obtained before administering a correction dose for high blood glucose levels
EXCEPT as noted below. Changes MUST be faxed to the school nurse at 973-7640066.
Glucose Levels
☐ Yes
☐ No
______Units if blood glucose is ______ to _____ mg/dl
______Units if blood glucose is ______ to _____ mg/dl
______Units if blood glucose is ______ to _____ mg/dl
______Units if blood glucose is ______ to _____ mg/dl
______Units if blood glucose 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
If parameters outlined above do not apply in a given circumstance:
a.
b.
Call parent/guardian and request immediate faxed order from
student’s physician/healthcare provider to adjust dosage.
If the student’s healthcare provider is not available, consult with the
school physician for immediate actions to be taken.
4. Students with Insulin Pumps
Type of pump: _________________________________B basal rates _____________ 12 am to _______
_____________ _______ to ______
_____________ _______ to ______
Type of insulin in pump: ____________________________________________________________________
Type of infusion set: _________________________________________________________________________
Insulin/carbohydrate ratio: _________________________________ Correction factor __________
5. Student Pump Abilities/Skills
Needs Assistance
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
Troubleshoot alarms and malfunctions
☐Yes
☐No
6. Student Taking Oral Diabetes Medication
Type of Medication: __________________________________________ Timing: __________________
Other Medication: ____________________________________________ Timing: __________________
7. Meals and Snacks Eaten at School
Is student independent in carbohydrate calculations and management? ☐Yes ☐No
Meal/Snack
Breakfast
Time
Food Content/Amount
______________________________
________________________________
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:
Instructions for class parties and food-consuming events:
8. Exercise and Sports
A fast-acting carbohydrate such as _________________________________________________________
should be available at the site of exercise or sports.
Restrictions on physical activity: ___________________________________________________________
Students should not exercise if blood glucose level is below ____________________mg/dl
or above _____________________ mg/dl or if moderate to large urine ketones are present.
Usual symptoms of hypoglycemia: _________________________________________________________
Treatment of hypoglycemia: ________________________________________________________________
Hypoglycemia: Oral glucagon/Cake icing or injectable Glucagon (Low Blood
Sugar)
______ Oral Glucagon/ or Cake icing _________________________________________________________
_________________________________________________________________________________________
______ Injectable Glucagon ___________________________________________________________________
_________________________________________________________________________________________
Preferred site for glucagon injection:
☐ arm
☐ thigh
☐ buttock
Once administered, call 911 and notify the parents/guardians.
9. 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: _____________________________________________________________________
10. Diabetes Care Supplies
While in school or at school-sponsored activities, the student is required to carry the
following diabetic supplies (check all that apply):
☐ Blood glucose meter, blood glucose test strips, batteries for meter
☐ Lancet device, lancets, gloves
☐ Urine ketone strips
☐ Insulin pump and supplies
☐ Insulin pen, pen needles, insulin cartridges, syringes
☐ Fast-acting source of glucose
☐ Carbohydrate containing snack
☐ Bottled Water
☐ Other (please specify)
This Diabetes Medical Management Plan has been approved by:
____________________________________________________________
Signature: Student’s Physician/Healthcare Provider
_____________________
Date
Student’s Physician/Healthcare Provider Contact Information (stamp):
This Diabetes Medical Management Plan has been reviewed by:
______________________________________________________________
School Nurse
________________________
Date
ROLLING HILLS PRIMARY SCHOOL
60 Sammis Road • P.O. Box 769 • Vernon, NJ 07462 • _Voice (973) 764-2784 • Fax (973) 764-3284
www.vtsd.com
Dear Parent/Guardian:
On October 1, 2009, the State of New Jersey adopted state N.J.S.A. 18A:40-12.11-21 governing
the care of students with diabetes in New Jersey public schools. This law requires schools to take
specific actions to ensure that students with diabetes are able to manage their disease while at
school and to ensure the health and safety of the student and the school community. As per the
above law, a volunteer glucagon delegate will be trained by the school nurse.
Please list below the activities the student is or will be participating in for the 20____/20____
school year. It is the responsibility of the parent or guardian to inform the school nurse of the
activities his/her child will be participating in throughout the school year. As per the above-cited
law, if the nurse is unaware of the activities, a volunteer delegate cannot be assigned to your
child.
_____________________________________________________
_____________________________________________________
_____________________________________________________
We have attached the required forms for your completion. Kindly have the forms returned to the
nurse’s office at the start of the _________________________ school year. If you have any
questions, please feel free to contact the nurse’s office at 973-764-2879.
Sincerely,
Jennifer Gallant RN, CSN
ROLLING HILLS PRIMARY SCHOOL
60 Sammis Road • P.O. Box 769 • Vernon, NJ 07462 • _Voice (973) 764-2784 • Fax (973) 764-3284
www.vtsd.com
PARENTAL REFUSAL OF A DELEGATE FOR GLUCAGON
This letter is to inform the Vernon Township School District that I DO NOT WISH for my child
______________________________________ to have a delegate for his/her glucagon
administration. I am aware that a school nurse may not be immediately available to assess the
severity of the diabetic reaction to administer glucagon for my child if he/she cannot administer it
himself/herself.
Parent
Signature______________________________________________________________
Date____________________________________________
ROLLING HILLS PRIMARY SCHOOL
60 Sammis Road • P.O. Box 769 • Vernon, NJ 07462 • _Voice (973) 764-2784 • Fax (973) 764-3284
www.vtsd.com
Indemnity and Hold Harmless, Permission for Care, and Release of Information
Statement for Diabetes Care
I give permission to the school nurse to perform and carry out the diabetes care tasks outlined in
the Diabetes Medical Management Plan (DMMP), Individualized Health Care Plan (IHP) and the
Individualized Emergency Health Care Plan (IEHP) designed for my child,
______________________________________________________.
I authorize the sharing of medical information about my child between my child’s physician or
advanced practice nurse and other health care providers in the school. I also consent to the release
of information contained in this plan to school personnel who have responsibility for or contact
with my child and who may need to know this information to maintain my child’s health and safety.
I understand that no school employee, including a school nurse, a school bus driver, a school bus
aide or any other officer or agent of the Vernon Township Board of Education, shall be held liable
for any good faith act or omission consistent with the provisions of N.J.S.A. 18A:40-12-11-21.
Signature of
Parent/Guardian______________________________________________________
Date ____________________________________________________________________