DIABETES INFORMATION PACKAGE
OOE Policy #11
Attachment 6A
NEW JERSEY DEPARTMENT OF CHILDREN AND FAMILIES (DCF)
OFFICE OF EDUCATION
DIABETES INFORMATION PACKAGE
DCF Regional School, __________________ Campus
DIABETES INTAKE CHECK LIST
Student: DOB:
Home Phone: Grade:
DATES
_____ 1. School’s nurse is notified that student with diabetes will be attending school.
_____ 2. Call or arrange a meeting with parent(s)/guardian(s) and student, if appropriate.
___ a. Discuss parent/student expectations of diabetes care while at school.
___ b. Discuss details of diabetes management plan and potential accommodations.
___ c. Discuss delegation of glucagon emergency administration by a trained volunteer, as appropriate, which includes parental consent.
___ d. Determine the equipment and supplies needed for school and obtain prior to student admittance.
___ e. Discuss plans for communication with parent and health-care team.
___ f. Request that parent sign an exchange of medical information form and release of confidential medical information form.
_____ 3. Meeting with parents, school’s nurse, and other members of the school staff, including a school bus driver and the student, where applicable.
Typical accommodations issues:
___ a. Management of low blood sugar
1) Who?
2) Where?
3) When?
4) How?
5) When and how to communicate to parents?
6) Restriction of activity?
___ b. Management of high blood sugar
1) Who?
2) Where?
3) When?
4) How?
5) When and how to communicate to parents?
6) Restriction of activity?
___ c. Blood testing
1) Who?
2) Where?
3) When?
4) What to do with results?
5) When and how to communicate to parents?
___ d. Insulin injections
1) Who?
2) Where?
3) When?
4) When and how to communicate to parents?
___ e. Meals (and snacks)
1) Who?
2) What’s too much or too little monitoring?
3) When and who to notify?
4) Where (location)?
5) Replacement?
6) Special occasions (parties, field trips).
___ f. Bathroom privileges
___ g. Access to drinking water
___ h. Transportation
1) Who?
2) What route?
3) When?
4) Other accommodations or equipment?
___ i. After-school activities
1) When?
2) Where?
3) Orders?
___ j. Identify and obtain legal documents for consent and authorization of treatment and exchange of information.
_____ 4. Review school-day schedule and assess level of independence.
_____ 5. Identify potential issues requiring accommodations.
_____ 6. Clarify health plan specific to Health-Care Provider Orders.
_____ 7. Identify staff for delegation to administer emergency glugagon. Complete training as appropriate (Attachment 14) and obtain parental consent (Attachment 6G).
_____ 8. Provide Diabetes training for all personnel working with student. Have all pertinent individuals sign the Individualized Health-Care Plan (IHP). Note the distribution.
_____ 9. Provide classroom education for students, if requested by parent or child.
_____ 10. Revise IHP and/or annually review IHP, as needed.
_____ 11. Adhere to the school’s bloodborne pathogen standard during blood testing.
OOE Policy #11
Attachment 6B
NEW JERSEY DEPARTMENT OF CHILDREN AND FAMILIES (DCF)
OFFICE OF EDUCATION
DIABETES INFORMATION PACKAGE
DCF Regional School, _______________Campus
HEALTH-CARE PROVIDER ORDERS
Student’s Name:________________________ Grade:
School Year: Date:
TASK ACTION(S)
Blood Glucose Testing ___for signs/symptoms of low blood sugar
___for signs/symptoms of high blood sugar
___times/week before lunch (specify days) Mon Tues Wed Thur Fri
___other (specify)
___not applicable
___notify parents immediately for blood sugar____mg/dl
___notify parents (specify) daily/weekly/monthly of any results done at school
___student may self-test
Urine Ketone Testing ___for blood sugar >____mg/dl
___for acute illness, e.g. vomiting, fever, etc.
___student must have unlimited access to restroom and drinking fountain/water bottle
___notify parents/guardians immediately for __________ ketones (NOTE: If parents cannot be reached and the student has __________ ketones and is vomiting, contact paramedics for transport to E.R.)
___notify parents (specify) daily/weekly/monthly of any results done at school
___other (specify)
___not applicable
___student may self-test
Meal Planning ___prescribed diet:_________________________________
___mid-morning snack at _____ A.M.
___mid-afternoon snack at _____ P.M.
___other (specify)
Activity ___no restrictions
___restrict gym/sports/etc. for ________________________
___Medical ID must be worn at all times including during gym/sports/etc.
___may attend class trips/field trips/etc.
___other (specify)
Insulin ___Daily Insulin Protocol/Coverage Scales (please include blood sugar check schedules and sliding coverage scales as relates to blood sugar and/or carbohydrate/diet intake). ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___student with insulin infusion pump shall be permitted to wear and attend to the pump
___not applicable
___other (specify)
___student may self-administer
Hypoglycemia/Glucagon ___Treat all blood sugar ................
................
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