Fort Mill School District #4
Diabetes Action Plan/ECP
School Year: __2013-2014____________ Homeroom Teacher: _______________
Student Name: _______________________________________
Home Address: _______________________________________
Parent/Guardian: _____________________________________
Date of Birth: __________________
Home Phone: __________________
Work/Cell: ____________________
Parent/Guardian: _____________________________________
Emergency Contact: __________________________________
Diabetes Doctor Name: ________________________________
Work/Cell: ____________________
Phone: _______________________
Phone: _______________________

When was your child first diagnosed with diabetes? ________________________________________

What type of diabetes does your child have? ( ) Type I ( ) Type 2

How many times has he/she been treated in the emergency room for diabetes in the past year? ______

How many times has he/she been hospitalized overnight or longer for diabetes in the past year? _____

How often does your child see his/her doctor for routine evaluations? __________________________

Please list any other medical conditions that your child has: __________________________________
__________________________________________________________________________________

Medication Allergies (please list): ______________________________________________________
CURRENT MEDICATIONS (please list all medications that your child takes):
NAME OF MEDICATION, DOSAGE & FREQUENCY MEDICATION TO BE TAKEN AT SCHOOL?
____ YES ____ NO ____ AS NEEDED
____ YES ____ NO ____ AS NEEDED
____ YES ____ NO ____ AS NEEDED
____ YES ____ NO ____ AS NEEDED
____ YES ____ NO ____ AS NEEDED
____ YES ____ NO ____ AS NEEDED
If medications are to be given during school, a medication consent needs to be filled out yearly. The prescribing physician must sign the medication consent for any prescription medication given at school. Medications must be in the original labeled container. (Most pharmacists will give you an extra labeled container to provide to the school if requested.)
Fort Mill School District #4
Form #DM100 Rev 08/2011 Page 1 of 7

Fort Mill School District #4
Diabetes Action Plan/ECP
CHECKING BLOOD GLUCOSE:
Target range of blood glucose: 70-130 mg/dL 70-180 mg/dL Other: _____________
Check blood glucose level: Mid-morning Before lunch ____ hours after lunch
2 hours after a correction dose Before PE After PE
Before dismissal Other: _________________________________________________
As needed for signs/symptoms of low or high blood glucose
As needed for signs/symptoms of illness
Brand/Model of blood glucose meter: _______________________________________________________
Preferred site of testing: Fingertip Forearm Thigh Other: ___________________
Note: The
, fingertip should always be used to check blood glucose level if hypoglycemia is suspected.
Student's self-care blood glucose checking skills:
Independently checks own blood glucose
May check blood glucose with supervision
Requires school nurse or trained diabetes personnel to check blood glucose
Continuous Glucose Monitor (CGM): Yes
Brand/Model: _____________________
N o
Alarms set for: (low) and (high)
Note: Confirm CGM results with blood glucose meter check before taking action on sensor blood glucose level. If student has symptoms or signs of hypoglycemia, check fingertip blood glucose level regardless of CGM.
Fort Mill School District #4
Form #DM100 Rev 08/2011 Page 2 of 7

Fort Mill School District #4
Diabetes Action Plan/ECP
HYPOGLYCEMIA TREATMENT:
Student's usual symptoms of hypoglycemia (please list): ____________________________________________
_________________________________________________________________________________________

If student is exhibiting symptoms of hypoglycemia, OR if blood glucose level is less than
______mg/dL, give a quick-acting glucose product equal to _______ grams of carbohydrates.

Recheck blood glucose in 10-15 mins. and repeat treatment if blood glucose level is less than
_______mg/dL.

Additional treatment:
______________________________________________________________________

If the student is unable to eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions (jerking movements), give:
 Glucagon: 1 mg 1/2 mg Route: SC IM
Site for glucagon injection: arm thigh Other: ___________________
 Call 911 (Emergency Medical Services) and the student's parents/guardian.
 Contact student's health care provider.
HYPERGLYCEMIA TREATMENT:
Student's usual symptoms of hyperglycemia (please list): ___________________________________________
_________________________________________________________________________________________

Check urine for ketones every ______ hours when blood glucose levels are above ______mg/dL.
 Additional treatment for ketones:
________________________________________________________

For blood glucose greater than _______mg/dL AND at least _______hours since last insulin dose, give correction dose of insulin (see orders below).

Insulin pump users : see additional information for student with insulin pump.

Give extra water and/or non-sugar-containing drinks (not fruit juices): ________ ounces per hour.

Notify parents/guardian of onset of hyperglycemia.

For symptoms of hyperglycemia emergency (dry mouth, extreme thirst, nausea & vomiting, severe abdominal pain, heavy breathing or shortness of breath, chest pain, increasing sleepiness, lethargy, or depressed level of consciousness: Call 911 (EMS) and the student's parents/guardian.

Contact student's health care provider.
Fort Mill School District #4
Form #DM100 Rev 08/2011 Page 3 of 7

Fort Mill School District #4
Diabetes Action Plan/ECP
INSULIN THERAPY:
Insulin delivery device: syringe insulin pen insulin pump
Type of insulin therapy at school:
Adjustable Insulin Therapy Fixed Insulin Therapy No insulin
Adjustable Insulin Therapy:

Name of insulin:_____________________________________________________________________

Carbohydrate Coverage:
Insulin-to-Carbohydrate Ratio:
Lunch: 1 unit of insulin per ____________ grams of carbohydrate
Snack: 1 unit of insulin per ____________ grams of carbohydrate
Carbohydrate Dose Calculation Example
Grams of carbohydrate in meal
Insulin-to-carbohydrate ratio = ___________ units of insulin

Correction Dose:
Blood Glucose Correction Factor/Insulin Sensitivity Factor = ________
Target blood glucose = __________ mg/dL
Correction Dose Calculation Example
Actual Blood Glucose – Target Blood Glucose
Blood Glucose Correction Factor/Insulin Sensitivity Factor = ____________ units of insulin
Correction dose scale (use instead of calculation above to determine insulin correction dose):
Blood Glucose __________ to ___________ mg/dL then give ___________ units
Blood Glucose __________ to ___________ mg/dL then give ___________ units
Blood Glucose __________ to ___________ mg/dL then give ___________ units
Blood Glucose __________ to ___________ mg/dL then give ___________ units
Fort Mill School District #4
Form #DM100 Rev 08/2011 Page 4 of 7

Fort Mill School District #4
Diabetes Action Plan/ECP
When to give insulin:
Lunch
Carbohydrate coverage only
Carb coverage + correction dose if glucose > ______ mg/dL and ______ hours since last insulin dose
Other: _________________________________________________________________________
Snack
No coverage for snack
Carbohydrate coverage
Carb coverage + correction dose if glucose > ______ mg/dL and ______ hours since last insulin dose
Other: ___________________________________________________________________________
Other miscellaneous times
Correction dose only if glucose > ______ mg/dL and ______ hours since last insulin dose
Fixed Insulin Therapy:
Name of insulin: _______________________________________________________________________
_________ units of insulin given pre-lunch daily
_________ units of insulin given pre-snack daily
Other: _________________________________________________________________________
Parental Authorization to Adjust Insulin Dose:
Yes
Yes
Yes
No
No
No
Parent/Guardian authorization should be obtained before administering a correction dose.
Parents/guardians are authorized to increase or decrease correction dose scale within the following range: +/- ___________ units of insulin.
Parents/guardians are authorized to increase or decrease insulin-to-carbohydrate ratio within the following range: ____ units per prescribed grams of carbohydrate, +/- ____ grams of carbohydrate.
Yes No Parents/guardians are authorized to increase or decrease fixed insulin dose within the following range: +/- _____ units of insulin.
Student's self-care insulin administration skill:
Yes No Independently calculates and gives own injections
Yes No May calculate/give own injections with supervision
Yes No Requires school nurse or trained diabetes personnel to calculate/give injections
Fort Mill School District #4
Form #DM100 Rev 08/2011 Page 5 of 7

Fort Mill School District #4
Diabetes Action Plan/ECP
ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP
Brand/Model of pump: Type of insulin in pump: ______________
Basal rates during school: ____________________________________________________
Type of infusion set: ________________________________________________________
For blood glucose greater than ______________ mg/dL that has not decreased within ______hours
after correction, consider pump failure or infusion site failure. Notify parents/guardian.
For infusion site failure: Insert new infusion set and/or replace reservoir.
For suspected pump failure: suspend or remove pump and give insulin by syringe or
pen.
Physical Activity:
May disconnect from pump for sports activity: Y e s N o
Set a temporary basal rate: Yes No _______% temporary basal for _____ hours
Suspend pump use: Y e s N o
Student's self-care pump skills:
Count carbohydrates
Independent?
Y e s N o
Bolus correct amount for carbohydrates consumed
Calculate and administer correction bolus
Calculate and set basal profiles
Calculate and set temporary basal rate
Change batteries
Disconnect pump
Reconnect pump to infusion set
Prepare reservoir and tubing
Insert infusion set
Y e s N o
Y e s N o
Y e s N o
Y e s N o
Y e s N o
Y e s N o
Y e s N o
Y e s N o
Y e s N o
Troubleshoot alarms and malfunctions Y e s N o
Fort Mill School District #4
Form #DM100 Rev 08/2011 Page 6 of 7

Fort Mill School District #4
Diabetes Action Plan/ECP
MEAL PLAN:
Breakfast
Meal/snack
Mid-morning snack
Time
__________
__________
__________
Carb Content (grams)
________ to _________
________ to _________
________ to _________ Mid-afternoon snack
Other times to give snacks and content/amount: _______________________________________________
Special event/party food permitted: Parents/guardian discretion
Student discretion
Student's self-care nutrition skills:
Y e s N o Independently counts carbohydrates
Y e s N o May count carbohydrates with supervision
Y e s N o Requires school nurse/trained diabetes personnel to count carbohydrates
PHYSICAL ACTIVITY AND SPORTS
A quick-acting source of glucose such as glucose tabs and/or sugar-containing juice must be available at the site of physical education activities and sports.
Student should eat: 15 grams 30 grams of carbohydrate other: ________________
before every 30 minutes during after vigorous physical activity
other: ______________________________________________________________________________
If most recent blood glucose is less than _______________ mg/dL, student can participate in physical activity when blood glucose is corrected and above ____________________ mg/dL.
Avoid physical activity when blood glucose is greater than ______________________ mg/dL or if urine/ blood ketones are moderate to large.
(Additional information for student on insulin pump is in the insulin section on page 6 .)
Parent: In case of serious accident or illness, I hereby authorize:
1.
the transfer of my child to the nearest hospital
2.
the administration of emergency treatment
I understand by signing below that this consent remains in effect the entire time my child is enrolled in school. The school will contact me as soon as possible if an emergency arises.
___________________________________________________ _____________________________________
Parent/Guardian Signature Date
I authorize school personnel to implement this Emergency Plan as described.
____________________________________
Health Care Provider Signature
Fort Mill School District #4
Form #DM100 Rev 08/2011
___________________________
Date
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