Dr. Michael Van Winkle
Assistant Superintendent
Michelle Thomas, RN, BSN
School Nurse
Jackson County School District
St. Martin Attendance Center
11300 Yellow Jacket Blvd * Ocean Springs, MS 39564
Phone 228-875-8418 ext. 612
Fax 228-875-8426
DIABETES ACTION PLAN
Student Information:
Name of student: _______________________________________________
DOB: _______________________
Grade: ______ Classsroom Teacher/1st Period Teacher: ________________________________________________
Physical Education Days and Times: _______________________________________________________________
Emergency Information:
Parent/Guardian Name: _____________________________________________ Phone (H) ___________________
Address: __________________________________________________ Phone (W) ___________________
Parent/Guardian Name: _____________________________________________ Phone (H) ___________________
Address: __________________________________________________ Phone (W) __________________
Physician’s name: _______________________________________________Telephone: _____________________
In case of emergency, contact:
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________
TO BE COMPLETED BY PHYSICIAN:

Target range of blood glucose: _______________________________

Specific dietary guidelines
Meal/snack times:
Breakfast ______________ AM snack _____________________ Lunch __________________
PM Snack _______________ Dinner ______________________ Bed ____________________

Blood glucose testing at school
This student is able to test his/her own blood glucose? __________ Yes __________ No
Dr. Michael Van Winkle
Assistant Superintendent
Michelle Thomas, RN, BSN
School Nurse
Adult supervision required? __________ Yes __________ No
Method to be used
Type of meter _____________________________________
Test strip required __________________________________
Routine testing times at school __________AM __________ Noon __________ PM
Supplemental testing times: _____ before exercise _____ after exercise _____before snacks
_____ with symptoms of high/low blood glucose Other _______________________________

Insulin at school
_____ not at all _____ routine lunchtime dose
_____ correction lunchtime dose
If insulin is required at school
Brand name and type: ____________________________________________________

Dose preparation by:
_____ Student
_____ Parent
_____ Parent designee
_____ Licensed nurse

Number of SQ or insulin pump units determined by:
_____ Student

Form used:
_____ Pre-filled syringe
_____ Insulin pen
_____ Insulin pump
_____ Licensed nurse
_____ Parent (telephone request acceptable)
Written sliding scale as follows:
Blood glucose from __________ mg/dl to __________ mg/dl = __________ units of insulin
Blood glucose from __________ mg/dl to __________ mg/dl = __________ units of insulin
Blood glucose from __________ mg/dl to __________ mg/dl = __________ units of insulin
Blood glucose from __________ mg/dl to __________ mg/dl = __________ units of insulin

SQ or insulin pump insulin administered by:
_____ Student
_____ Parent
_____ Parent designee
_____ Licensed nurse
_____ Student with staff verification of the number of prescribed insulin units
(all parent designees are trained by the parent and are not employees of the school or district)

Specific sports/exercise guidelines:
1.
This student may participate in daily PE? _____ Yes _____ No
2.
After school sports? _____ Yes _____ No
3.
Activity restrictions: _____ None _____ Other _________________________________
4.
Exercise should be delayed or avoided if blood glucose is higher than __________ mg/dl or lower
than __________mg/dl.

Treatment of LOW BLOOD GLUCOSE: (See signs & symptoms of low blood glucose) Low blood
glucose must be treated immediately. An adult must stay with student until all signs and/or symptoms of
low blood glucose are gone and blood glucose is 70mg/dl or higher.
THIS IS AN EMERGENCY. IMMEDIATE TREATMENT IS NEEDED.
This student’s blood sugar is considered low if __________ mg/dl or lower.
Dr. Michael Van Winkle
Assistant Superintendent
Michelle Thomas, RN, BSN
School Nurse
If the student is conscious and able to swallow give one of the following:
ITEM
__________________________
__________________________
AMOUNT
_________________________
_________________________
If the student is less cooperative then give one of the following:
ITEM
AMOUNT
__________________________
__________________________
ROUTE
_________________________
_________________________
_____________________
_____________________
If student begins to lose consciousness or is having a seizure, call 911 and parents immediately.
If present and ordered by the physician, the school nurse may administer glucagon emergency kit.
_____ Yes _____ No

Treatment of HIGH BLOOD GLUCOSE (See signs & symptoms of high blood glucose)
1.
2.
3.
4.
The student is hyperglycemic if blood glucose is above __________ mg/dl.
Are urine ketones to be check at school? _____ Yes _____ No
Check urine ketones if glucose is above _____ mg/dl _____ by student independently _____ with
assist. Notify parents or physician if ketones are positive or when _________________________
Additional actions to be taken: (see insulin at school section) _____________________________
______________________________________________________________________________.

In the event of field trips, all diabetic supplies are taken and care is provided according to the Action Plan
(a copy if taken on trip)

In the event of classroom/school parties, food treats will be handled as follows:
_____ Student will eat the treat
_____ Put in baggie and take home with teacher note

_____ Replace with parent supplied alternative
_____ Modify treat as follows _______________
3 day disaster diabetes supplies are recommended:
_____ vial of insulin, 6 syringes
_____ Glucagon kit
_____ insulin pen with cartridge and needles
_____ ketone strips/plastic cup
_____ glucose gel product and glucose tablets
_____ snack supply
_____ blood glucose testing kit (testing strips lancing device with lancets)
PARENT CONSENT FOR DIABETES MANAGEMENT IN SCHOOL
The undersigned parent/guardian of the above-named student request that the specialized physical health care
service for management of diabetes in school is administered to student. Parent will provide the necessary supplies
and equipment, notify school if there is a change in student health status or attending physician and notify the school
nurse immediately and provide new consent for any changes in doctor’s orders. I authorize the school nurse to
communicate with the physician when necessary.
Parent/Guardian Signature _________________________________________
Date ________________________
Dr. Michael Van Winkle
Assistant Superintendent
Michelle Thomas, RN, BSN
School Nurse
PHYSICIAN CONSENT FOR DIABETES MANAGEMENT IN SCHOOL
My signature below provides authorization for the above written orders. I understand that specialized physical
health care services may be performed by unlicensed designated school personnel under the training and supervision
of the school nurse. The authorization is for maximum of one year.
Physician Signature ___________________________________________
Date ________________________
Reviewed by School Nurse _____________________________________
Date ________________________