Student Name



|Student Name |Sex |Date of Birth |

| |( Female | |

| |( Male |_______/_________/_____________ |

| | |Month Day Year |

|School |Grade |Counselor/Teacher |

|( MAS ( CENT ( MUR ( CHATS ( HMX ( HS ( Other: | | |

|EMERGENCY SITUATIONS |Diagnosis ( Type 1 Diabetes ( Type 2 Diabetes |

| |( Other |

|Severe Hypoglycemia |Risk for Diabetic Ketoacidosis (DKA) |Blood Glucose Monitoring & Insulin Orders |

|( Give Glucagon and Call 911 |( Ketones: Test ketones if hyperglycemic*, vomiting, |Student |

|PRN for unconsciousness, |or fever ≥ 100.5. If initial or retest ketones are |May check bG without supervision |

|unresponsiveness, seizure, or |moderate or large, give water and: |May check bG with supervision |

|inability to swallow EVEN if the |( Call parent and/or MD ( No PE |Must have school personnel check bG |

|bG is unknown. Turn onto left |( If vomiting, unable to take PO, and MD not available, |May give insulin without supervision |

|side to prevent aspiration. |CALL 911 |May give insulin with supervision |

|1 mg SC/IM |( Give insulin, if ordered below |Must have school nurse give insulin |

|_______ mg SC/IM | | |

| |( Lunch |( Snack |( PE |( PRN |

| | | | | |

|Hypoglycemia |For bG < _____ mg/dL |For bG < _____ mg/dL |For bG < _____ mg/dL |For bG < ______ mg/dL |

| |Give ______ oz juice, |Give ______ oz juice, |Give ______ oz juice, |Give ______ oz juice, |

| |or ______ glucose tabs, or ______ |or ______ glucose tabs, or ______ |or ______ glucose tabs, or ______ |or ______ glucose tabs, or gm |

| |gm carbs |gm carbs |gm carbs |carbs |

| |Recheck in ______ minutes; |Recheck in ______ minutes; |Recheck in ______ minutes; |Recheck in ______ minutes; |

| |If bG < ______, repeat carbs and |If bG < ______, repeat carbs and |If bG < ______, repeat carbs and |If bG < ______, repeat carbs |

| |recheck until bG > ______. |recheck until bG > ______. |recheck until bG > ______. |and |

| |THEN |THEN | |Recheck until bG > ______. |

| | | |( If initial bG < ______, No PE | |

| |( Give insulin BEFORE lunch |( Give insulin BEFORE snack |( Give snack AFTER treatment THEN |( Give snack after treating |

| |( Give insulin AFTER lunch |( Give insulin AFTER snack |send student to PE |hypoglycemia |

|Between |( Give insulin BEFORE lunch |( Give insulin BEFORE snack |( Give snack BEFORE PE | |

|Hypo-and | | | | |

|Hyperglycemia |( Give insulin AFTER lunch |( Give insulin AFTER snack |( Send to PE | |

| | | | | |

|Hyperglycemia |( Test ketones if bG >______ mgdL |( Test ketones if bG >______ mgdL |( Test ketones if bG >______ mgdL |( Test ketones if bG >______ mgdL |

| |Treat as per Risk for DKA above |Treat as per Risk for DKA above |Treat as per Risk for DKA above |Treat as per Risk for DKA above |

|* bG > ______ | | |For bG > ______ mg/dL, no PE |For bG > ______ mg/dL, no PE |

| |( Give insulin BEFORE lunch |( Give insulin BEFORE snack |For bG > ______ mg/dL, AND at least |For bG > ______ mg/dL, AND at |

| | | |______ hours since last insulin, |least ______ hours since last |

| |( Give insulin AFTER lunch |( Give insulin AFTER snack |give insulin according to: |insulin, give insulin according to: |

| | | |( Correction Dose, OR |( Correction Dose, OR |

| | | |( Sliding Scale |( Sliding Scale |

| | | |(orders below) |(orders below) |

|Carb Coverage |( Carb coverage only |( Carb coverage only | | |

|Insulin |( Carb coverage PLUS Correction |( Carb coverage PLUS Correction | | |

|Instructions |Dose when bG > Target bG |Dose when bG > Target bG | | |

|INSULIN ORDERS ( Carb Coverage (plus Correction Dose ( Sliding Scale ( Carb Coverage plus Sliding Scale ( No Insulin at School |

|(CHECK ONE BOX ONLY) if ordered above) for Correction |

|Glucose Monitoring ONLY |

|( Syringe / ( Pen |Name of Insulin |( Insulin Pump (Brand & Model) |

|Target (Single #) |Sensitivity Factor (Correction) |Insulin:Carb For LUNCH For SNACK |Basal In School | ( Disconnect |

| | | |Rate ______ units/hour |pump for PE |

|bG = ______ mg/dL |1 unit will decrease bG by ______ mg/dL |Ratio: (I:C) 1: ______ gms 1: ______ | | |

| | |gms | | |

| |For Pump: |

|Round DOWN the insulin dose to the closest 0.5 units for syringe/pen |( Follow Pump recommendation for bolus |

| |dose [If not using Pump recommendation, |

| |round DOWN the dose down to the nearest |

| |0.1 unit] |

| |( For bG > ______ mg/dL that has not |

| |decreased ______ hours after correction, |

|Example: Current bG = 250 Target bG = 150 Sensitivity Factor = 100 Insulin:Carb ratio = 1:20 Lunch carbs = 60 |consider pump failure. Notify parent. |

|gms |( For suspected pump failure: |

| |DISCONNECT pump and give insulin by |

|Carb Coverage 60 gms carb |syringe or pen. |

|250 — 150 | |

|Plus 20 | |

|100 | |

|Correction Dose TOTAL DOSE: 3 + 1 = 4 UNITS | |

|SLIDING SCALE |( Pre lunch bG Range Insulin |( Other time bG Range Insulin |

|Name of Insulin |Units |Units |

| |To |To |

|_________________________________ |To |To |

|Please do NOT overlap ranges (e.g. 100-200, 200-300, |To |To |

|etc.). |To |To |

|If ranges overlap, the lower dose will be given. | | |

|SNACK: |HOME MEDICATIONS: |OTHER DIABETES ORDERS: |

|Time of day: ____________________ | | |

|Type & Amount: | | |

| | | |

| | | |

|( Student may carry and self administer snacks | | |

| |Insulin (Dose, Frequency and Time): | |

| | | |

| |Oral Medications (Dose, Frequency, and Time): | |

| | | |

|Health Care Practitioner Name (Please Print) |Tel No. |Parent Signature( |

|Health Care Practitioner Signature |Fax No. |Date |

|Address |Date | |

| | |( Parent signature denotes permission to share the above |

| | |student’s medical information with staff on a |

| | |need-to-know basis and also gives permission to speak to |

| | |child’s physician/practitioner as needed. |

|PLACE OFFICE STAMP HERE | | |

-----------------------

Carb Coverage =

# gms carb in meal bG — Target bG

# gms carb in I:C Sensitivity Factor

Correction Coverage =

= # units

insulin

= # units insulin

Carb Coverage:

= 1 unit

= 3 units PLUS Correction Dose:

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