IHP Diabetes Medical Management Plan:
School Year ___ - ___
Date: ___
DOB: ___
Contact Information:
Diabetes: _____Type 1 ____Type 2
Date of Diagnosis: ___
Last A1C Result: ___
Student Name: ___
Grade:___
Homeroom teacher:___
School Attending: ___
Contact Person: _____
Phone: ___
Fax: ___
Parent Contact Information: Relationship:___
Parent/Guardian # 1:___
Phone: Home:___
Parent Contact Information: Relationship:___
Parent/Guardian # 1:___
Phone: Home:___
Work/Cell:___
Work/Cell:___
Emergency Contact:___
School District:___
Phone:_____
___ MPS
Relationship:___
Provider Treating Student for Diabetes:____
Emergencies: 414-266-2860
___ Milwaukee: 9000 West Wisconsin Ave, Milwaukee, WI 53201 Phone: 414-266-3380 Fax: 414-266-3964
email: diabetesclinic@chw.org
___ Fox Valley: 130 2nd Street, West Pavilion, Neenah, WI 54956* Phone: 920-969-7970 Fax: 920-969- 7979
email: fvdiabetesclinic@chw.org
Emergency Notification: Notify parents of the following conditions.
a. Loss of Consciousness or seizure (convulsion) immediately after Glucagon given and 911 called.
b. Blood sugars over ______________mg/dl
c. Moderate to large Urine Ketones
d. Abdominal pain, nausea/vomiting, diarrhea, fever, altered breathing or altered level of consciousness
*If unable to reach parents call emergency number 414-266-2860.
Supplies: To be furnished and re-stocked by Parents/Guardian
The Student requires the following supplies
Blood glucose monitor & test strips
Lancets & lancet device
Urine ketone test strips
Yes
No
Yes
Insulin pen
____ ____
____ ____ Insulin pen needles or syringes
____ ____ Insulin – cartridge, pen device, vial
____ ____
____ ____
____ ____
____ ____ Extra insulin cartridge, pen device, vial
____ ____ Sharps container
____ ____
____ ____
____ ____
____ ____
(Must be replaced every 28 days)
Glucagon Emergency Kit
Fast acting sugar source
Complex carbohydrate snack
Monitoring: _____Yes _____ No
No
Current Meter: _____
If yes, can student perform own blood glucose checks? ___Yes ___ No Needs Supervision:___Yes___No Interprets results:___Yes___No
Document result and send copy home with student weekly ___Yes___No
___Before Breakfast
Times to be performed:
___Before PE/Activity ____
___Midmorning: before snack
___After PE/Activity ___
___Before Lunch
___Mid-afternoon
___Dismissal
___As needed for signs/symptoms of low/high Blood Glucose
___First 2 weeks of Pump Therapy – Check every 2 hours
Place to be performed: ____Classroom____Clinic/Health Room ____Other ___
Optional: Target Range for blood glucose:__ _mg/dl to__mg/dl. (Completed by Healthcare Provider)
IHP Diabetes Medical Management Plan:
Page 2
Insulin Administration during school:____Yes____No
If yes: Can student – Determine correct dose?____Yes____No
- Give own injections?_____Yes_____No
Prepare own dose? ____Yes ____No
Need supervision?_____Yes_____No
Insulin Delivery:____Pen____Pre-drawn syringe____Syringe/vial_____ Pump * Deliver dose via pump___Yes____No
* For dose see insulin dosing guidelines
Other routine Diabetes medications at school: ____Yes ____No
Name of Medication
___
___
:
Dose:
___
___
Time
___
___
Route:
___
___
Exercise, sports and field trips:
___ Quick Access to all supplies needed for cares including: Blood Glucose monitoring, snacks, per IHP plan,
sugar-free liquids, fast-acting carbohydrate snacks.
____Child should not participate in exercise if Blood Glucose is below ____mg/dl
or if ___
Food at School
Meal & Snack Plan
Meals/Snacks:
1 Carb serving = 15grams of carbohydrates.
___ Student can independently count carbohydrates.
___ Needs assistance with carbohydrate counting for snacks and meals
Meal/Snack
___Grams of Carbohydrate
___Carb Servings
Amount eaten at each meal
Time
___
____
___
___
___
___
___
___
In addition to the above meal plan, the student may require an extra snack: ____Before Gym ____after gym____only when needed
Breakfast
Mid-morning snack
Lunch
Mid-afternoon snack
This document follows the guiding principles outlined by the American Diabetes Association.
Signatures:
I/we understand that all treatments and procedures may be performed by the student and/or trained unlicensed personnel within the
school or by EMS in the event of loss of consciousness or seizure. I also understand that the school is not responsible for damage, loss or
equipment, or expenses utilized in these treatments and procedures. I have reviewed this information sheet and agree with the
indicated instructions. This form will assist the school health personnel in developing a nursing care plan.
Parent’s Signature:___
Date:_ __
Student Signature: ___
Date: ___
School Nurse or Designee: Signature:___
Date: ___
Plan Completed by:_ _ _
Date:___
Provider Signature:_ _ _
Date: ___
IHP Diabetes Medical Management Plan:
Page 3
Emergency Treatment
Low Blood Sugar Treatment: Symptoms for this student may include
____Hunger
____Confusion
____Sleepiness
____Poor Coordination
____Other_ _____________
____Sweating
____Crying
____Headache
____Personality change
____Trembling or Shaking
____Inability to concentrate
____Dizziness
____Complaints of feeling “low”
____Appears Pale
____Fast Heart Beat
____Slurred Speech
____Blurred Vision
Treat Blood Glucose less than _______mg/dl. If student is awake and able to swallow give _________grams fast acting
carbohydrates such as:
____4 oz. Juice or____4 to 6 oz of regular soda or ____3 – 4 glucose tablets____Concentrated gel or frosting tube
OR ____Other-(provided by parent)_______________________ _____ Notify Parents of low blood glucose reaction.
_____Re-test Blood Glucose in 15 – 20 minutes. Repeat treatment until Blood Glucose level is over _________mg/dl.
_____If more than one hour until next meal/snack follow with a 15 gram of carbohydrate snack such as_______________________
_____If Student wears a pump:
_____If Blood Glucose is below 80 mg/dl for two checks in a row, suspend pump for 15 minutes.or until BG is over 80
_____If Blood Glucose is below one time _____mg/dl suspend pump for _____mins or until BG is over ______
For any student experiencing a low Blood Glucose Level 
 If student is not responding to treatment, call parent right away.
 Do not leave student alone or allow him/or her to leave the classroom without an adult to accompany
Give Glucagon Injection ( Follow package instructions for mixing) If student is not able to eat or drink, experiencing
a seizure, and/or is unconscious . CALL 911 – Do not leave student Unattended!
Dose: _____Give half the dosage (0.5mg) _____Give whole dosage (1.0 mg)





Turn student on their side and keep airway clear. Do not insert objects into mouth or between teeth.
The student may vomit, never leave them unattended.
The student will need to go to the nearest emergency room to be evaluated after receiving glucagon.
The student’s parents/guardians must be notified.
____If student wears a pump – disconnect or cut tubing
High Blood Sugar Treatment: Symptoms for this student may include:
____Dehydration
____Increased thirst
____Inability to concentrate
____Sleepiness
____Hunger
____Confusion
____Irritability
____Blurred Vision
____Frequent urination
____Headache
____Dry skin
____Other _______________
If student is experiencing symptoms of high blood glucose Check Blood Glucose
OR if Blood Glucose is over ___________mg/dl
____Administer correction dose of insulin
____Allow student to drink water or sugar free fluids
____Allow access to the bathroom
____Check Urine Ketones
(If student wears a pump, ketones must be checked)
(Refer to specific dosing guidelines for correction dose on individual dosing sheet)
____Student will need assistance with correction dose administration.
____Pump Use: check set, site, connection and reservoir for problems.
____Pump Use:If blood glucose remains out of range at next check
correction must be given with syringe or pen.
Notify Parents of high blood glucose treatment.
Notify Parents Immediately if:
 Moderate to large ketones are present
 If high blood glucose symptoms persist or worsen
 If the student is vomiting
 Correction dose of insulin is given other than at meal time.
If the student has difficulty breathing and lethargy, or if parents do not respond immediately;
Call the Diabetes Emergency Line at 414-266-2860 or call 911 for Emergency assistance.