Management of Diabetes at North Bay Order Form
This order is valid only for the dates the student is attending camp.
Student: __________________________________________
DOB: ______________
School: __________________________________
Dates at camp: _______________________________
CONTACT INFORMATION:
Parent/Guardian: __________________________ Home Phone: _______________ Work: _________________ Cell:___________________________
Other Emergency Contact: ________________________ Home Phone: ____________________Work: _________________Cell: __________________
INSULIN ORDERS:
1. Insulin administration via:
� Syringe and vial
� Insulin pen
� Insulin pump
� Other _______________________________
If on insulin pump indicate type of pump ______________________ and basal rates ____________________
*must also fill out insulin pump form
2. Insulin Before Meals and at Bedtime: Name of insulin: _____________________
� Routine dose: __________________________ 
� Per sliding scale as follows
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
Blood Glucose ________ to ________ give _________ units
� Calculated insulin dose (add carbohydrate coverage and correction dose for total insulin does):
 Carbohydrate Coverage: Insulin to carbohydrate ratio
o Give _______ units insulin per _______ grams carbohydrate
o Correction: Give _______ units insulin per _______ mg/dl of glucose above _______ mg/dl
Subtract _______ units insulin per _______ mg/dl of glucose below _______ mg/dl
3. Other times insulin may be given:
� Snack: � Dose: ___________  � Calculated as above
� Ketones:
If ketones are __________ Give/Add __________ units
If ketones are __________ Give/Add __________ units
Health Care Provider Authorization for Management of Diabetes at North Bay Camp
My signature below provides authorization for the above written orders. This authorization is for while the student is
attending North Bay Camp.
Health Care Provider Name: _________________________________ Signature: _______________________________
(original or stamped signature) *Sign both sides.
Phone: _______________________ Fax: ___________________________Date: ___________
Parent Consent for Management of Diabetes at North Bay Camp
I (We) request designated North Bay personnel to administer the medication and treatment orders as prescribed above. I
agree:
1. To provide the necessary supplies and equipment
2. To notify the school nurse if there is a change in the student’s diabetes management or health care provider.
I authorize the school nurse to communicate with the health care provider as necessary.
Parent/Guardian Signature __________________________________________________ Date ____________________
*Sign both sides.
Order reviewed and signed by Camp Nurse: ___________________________________________ Date: ______________
North Bay Management of Diabetes at Camp Order Form
Student: ______________________________ School: _______________________ Dates attending: _______________
Blood Glucose Monitoring:
Target range for blood glucose monitoring at school: ___________________________
� Before snacks
� 2 hours or _______ hours after lunch
� Before meals
� 2 hours or ______ hours after a correction dose
� As needed for symptoms of hypo/hyperglycemia
� With signs and symptoms of illness
� Other times: ______________________
Hypoglycemia – Blood glucose less than __________
� Self-treatment for mild lows.
� Give ____ grams of fast-acting carbohydrate according to care plan. Recheck BG in 10-15 min. Repeat treatment if BG < ____ mg/dl
� Provide extra protein & carbohydrate snack after treating low if next meal/snack is greater than ______ minutes away
� Suspend pump for severe hypoglycemia for ______ minutes
If student is unconscious, having a seizure or unable to swallow, presume student is having a low blood sugar Call 911 &
notify parent and school point person.
� Glucagon injection (1mg in 1cc) _______mg, SQ or IM
� OK to use glucose gel inside cheek, even if unconscious or seizing
� Other: _________________________________
Hyperglycemia – Blood glucose greater than ___________
� Check urine ketones, follow care plan, administer insulin as per orders. � For pumps, insulin may be given by syringe or pen if needed
� Encourage sugar free fluids, at least ______ ounces per ______.
� If student complains of nausea, vomiting or abdominal pain; check urine ketones and check insulin administration orders.
� Other: _________________________________________
** Transport to local ED may be needed with vomiting and large ketones. **
Meal Plan
� AM snack time: _______
� PM snack time: ________ � Avoid snack of BGL is > ______ mg/dl.
� Breakfast¨___________ � Lunch: ______________ � Dinner: ___________
� Extra food allowed: � Parent discretion
� Student discretion
Exercise (check and/or complete all that apply)
Fast-acting carbohydrate source must be available before, during and after all exercise
� With student
� With teacher
If most recent blood glucose is less than ________, exercise can occur when blood glucose is corrected and above _________
� Eat ______ grams of carbohydrate; � Before exercise
� Every 30 minutes during
� After vigorous exercise
� Avoid exercise when blood glucose is greater than ________ or ketones are _________
Bus Transportation
� Blood glucose monitoring not required prior to boarding bus
� Check blood glucose 15 minutes prior to boarding bus
� Allow student to eat on bus if having symptoms of low blood glucose
� Provide care as follows: _________________________________________________________________________________________
Health Care Provider Assessment
Student can self-perform the following procedures (school nurse and parent must verify competency):
� Blood glucose monitoring
� Measuring insulin
� Injecting insulin
� Determining insulin dose
� Independently operating insulin pump
� Other: _______________________________________________________________________________________________________
Disaster Plan (if needed for lockdown, 24hr shelter in place):
� Follow insulin orders as on Management Form
� Additional insulin orders as follows: ______________________________________________________
� Administer long acting insulin as follows: ________________________________________________________________
� Other: ______________________________________________________________________________________________________
Other Instructions:
_______________________________________________________________________________________________________________
Health Care Provider Signature (required): ______________________________________ Phone: ______________ Date: __________
Parent Signature (required): __________________________________________________ Phone: _______________ Date: _________
Order reviewed by North Bay nurse: ___________________________________________________________ Date: _______________