Not intended to be copied or
used as a model IHP
SAMPLE INDIVIDUALIZED HEALTH PLAN
DIABETES
CONFIDENTIAL
CONFIDENTIAL
IDENTIFYING INFORMATION:
Student:
DOB:
Home phone:
Mother:
Work phone:
Cell phone:
Father:
Work phone:
Cell phone:
School:
Phone:
Physician:
Phone:
Nurse (Supervisor of IHP Care)
Phone:
Fax:
HEALTHCARE INFORMATION:
Hospital of choice:
Health concern:
Date of diagnosis:
Routine management of condition:
Routine management target blood sugar range:
REQUIRED TESTING FOR DIABETIC:
Required blood sugar testing at school:
Times to test blood sugar:

Before lunch:
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Before snack:
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As needed for signs/symptoms of low/high blood sugar:
NOTE: Call parent if blood sugar values are below _____or above ____.
MEDICATIONS:
Medications to be given during school hours:
Procedure for:
Times to be given:
Other pertinent information:
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SAMPLE INDIVIDUALIZED HEALTH PLAN
DIABETES
CONFIDENTIAL
CONFIDENTIAL
DIET INFORMATION:
Lunch time:
Snack time:
Location where snacks are kept
ACTIVITY INFORMATION:
Recess time:
PE time:
Parents are responsible for maintaining necessary supplies, snacks, medications, and equipment.
SAMPLE EMERGENCY RESPONSE PLAN FOR DIABETIC STUDENT
LOW BLOOD SUGAR (hypoglycemia)
Below 100
With any level of low blood sugar never leave student alone.
Student should be treated when blood sugar is below 100.
If blood sugar not above 100 after 3 treatments or if low blood sugar recurs without
explanation, contact parents for potential instructions to suspend pump.
Symptoms could include: dizziness, shakiness, hunger, weakness, pallor, sweatiness, headache,
irritability, confusion, restlessness, combativeness and/or other changes in behavior.
MILD LOW BLOOD SUGAR:
80 to 100
Check blood sugar.
If blood sugar is between 80 and 100, treat immediately as listed below:
 Give 1 juice box OR 1 package fruit snacks.
 Recheck blood sugar in 15 minutes.
 If blood sugar is still less than 100, re-treat and re-test until blood sugar is 100 or above.
If blood sugar is low before a meal or snack:
 Treat the low blood sugar first and get it back up to target range.
 Bolus for the food eaten after the blood sugar is back into target range. Never count
treatment carbohydrates into the amount you need to bolus. Never give a corrective dose
after treatment of a low.
Comments: Student will often not experience any symptoms in this range of low blood sugar.
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SAMPLE INDIVIDUALIZED HEALTH PLAN
DIABETES
CONFIDENTIAL
MODERATE LOW BLOOD SUGAR:
CONFIDENTIAL
60 to 80
Check blood sugar (Student may need assistance).
If blood sugar is between 60 and 80, treat immediately as listed below:
 Give 1 juice box OR 1 package fruit snacks.
 Recheck blood sugar in 15 minutes.
 If blood sugar is still less than 100, re-treat and re-test until blood sugar is 100 or above.
If student is conscious yet unable to effectively drink the fluids offered:
 Administer 1 tube of glucose gel, placed between the cheek and the gums.
 Massage into gums, elevate head, and encourage student to swallow. (Student may be
uncooperative).
 Notify parents
 Retest in 15 minutes. If still below 100, re-treat as above.
 Continue to re-test and re-treat until blood sugar is 100 or above.
SEVERE LOW BLOOD SUGAR:
Less than 60
Check blood sugar (Student will most likely be unable to do so).
If sugar less than 60, treat immediately with 2 juice boxes.
 Notify parent.
 Recheck in 15 minutes.
 If still less than 60, re-treat with 2 more juice boxes.
 If more than 60 but less than 100, re-treat with 1 juice box or 1 package fruit snacks.
 Re-test and re-treat until blood sugar is 100 or above.
 If it is 1 hour or more until lunch or snack time, give student 1 package of cheese and
crackers.
EMERGENCY TREATMENT IF SEIZING OR UNCONSCIOUS
Send someone to call EMS and then to notify parents.
If seizing or unconscious, treat immediately:



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Administer 1 vial of glucagon SQ or IM.
Turn student on his left side.
Stop insulin pump by disconnecting at pump site.
Test blood sugar every 10 minutes until EMS arrives.
(If student arouses before EMS arrives, give sips of apple juice).
Send pump with EMS to hospital.
DO NOT GIVE LIQUIDS OR GELS WHILE UNRESPONSIVE.
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SAMPLE INDIVIDUALIZED HEALTH PLAN
DIABETES
CONFIDENTIAL
HIGH BLOOD SUGAR
CONFIDENTIAL
Above 250
Call parent when sugar is above 250.
Symptoms could include: extreme thirst, extreme hunger, frequent urination, headache,
abdominal pain, and/or nausea.
Procedure for treating high blood sugar:




Check blood sugar.
If more than 200 but less than 250, encourage student to drink water and allow unlimited
restroom breaks.
If greater than 250, notify parent.
Monitor student until parent arrives; parent will follow up with the decision making for
how to treat the high blood sugar.
FIELD TRIP INFORMATION


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
Please notify parents of field trip plans as early as possible.
Information that the parent should know are date, time of departure and return,
destination, planned meals, and planned activity level.
Extra snacks, blood glucose monitor, copy of health plan, glucose gel and glucagon must
accompany student on a field trip.
Student’s parent agrees to accompany him on all field trips.
TREATMENT SUPPLIES TO BE KEPT AT SCHOOL AT ALL TIMES

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



Blood glucose meter and blood glucose strips
Lancets with lancing device
Urine ketone strips
Apple juice and fruit snacks
Bottled water or water bottle
Glucose gel
Glucagon emergency kit
Extra battery for pump
Coin to open pump
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SAMPLE INDIVIDUALIZED HEALTH PLAN
DIABETES
CONFIDENTIAL
CONFIDENTIAL
AGREEMENT FOR CARE
As a parent of _________________________, I hereby give my permission to trained staff at
_______________ School to perform and carry out the tasks as outlined in this Individualized
Health Plan (IHP) under the supervision (by telephone) of _______________________ (licensed
healthcare professional). I understand that the information contained in this plan will be shared
with school staff only on a need-to-know basis. It is the responsibility of the parent to notify the
school whenever there is any change in the student’s health status or care.
Mother (Guardian): _______________________________________
Date: ____________
Father (Guardian): ________________________________________
Date: ____________
IHP Developed by:
Physician:
______________________________________
Date: ____________
(Nurse Practitioner, Registered Nurse, or other licensed healthcare professional)
I have reviewed this Individualized Health Plan and accept the plan of care for this student
during school hours.
Principal: _________________________________________________
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Date: ____________