This plan should be completed by the student’s personal health care team and parents/guardian. It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel. Student’s Name: _______________________________________________________________ Grade: ___________ Date of Birth: ________________________________ Date of Diabetes Diagnosis: ______________________________
: _________________________________________________________________________________
Home - ________________________ Work - ___________________________ Cell -__________________________
Father/Guardian: __________________________________________________________________________________
Home - ________________________ Work - ___________________________ Cell -__________________________
Student’s Doctor/Health Care Provider: Name: _________________________________________________________
Address: _________________________________________________________________________________________ Telephone: _______________________________________________________________________________________ Emergency Number: ________________________________________________________________________________ Notify parents/guardian in the following situations: _________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
HYPOGLYCEMIA (Low Blood Sugar)
Usual Symptoms of hypoglycemia: ____________________________________________________________________
________________________________________________________________________________________________ Treatment of hypoglycemia: __________________________________________________________________________ ________________________________________________________________________________________________
Glucagon should be given if the student is unconscious, having a seizure (convulsion), or unable to swallow.
Route __________________, Dosage _____, site for glucagon injection: ____ arm, ____ thigh, ______________other.
If glucagon is required, administer it promptly. Then call 911 (or other emergency assistance), the school nurse,
and the parents/guardian.

HYPERGLYCEMIA (High Blood Sugar)
Usual Symptoms of hyperglycemia: ___________________________________________________________________
________________________________________________________________________________________________ Treatment of hyperglycemia: _________________________________________________________________________ ________________________________________________________________________________________________ Urine should be checked for ketones when blood glucose level is above _________ mg/dl. Treatment for ketones: None Present: _____________________ Small: _______________________ Moderate: ________________________ Large: _______________________ BLOOD GLUCOSE MONITORING
Target range for blood glucose is: □ 70-150 Usual times to check blood glucose: ___________________________________________________________________ Times to do extra blood glucose checks (check all that apply) □ before exercise □ other (explain) ______________________________ □ when student exhibits symptoms of hyperglycemia □ when student exhibits symptoms of hypoglycemia Can student perform own blood glucose checks? Exceptions: ______________________________________________________________________________________ Type of blood glucose meter student uses: ______________________________________________________________ INSULIN
Usual Mealtime Dose
Base dose of regular Humalog/Novalog (circle type) insulin at breakfast is ____ units or does flexible dosing using
____ units/____grams of carbohydrate.
Use of other insulin at breakfast: intermediate NPH/Lente (circle type) ____ units or basal Lantus/Ultralente ____ units. Base dose of regular Huma log/Novalog (circle type) insulin at lunch is ____ units or does flexible dosing using
____ units/ ____ grams carbohydrate.
Use of other insulin at lunch: (circle type) : intermediate NPH/Lente ____ units or basal Lantus/Ultralente ____ units. Use of other insulin in evening: (circle type): intermediate NPH/Lente ____ units or basal Lantus/Ultralente ____ units.
Parents are authorized to adjust the insulin dosage under the following circumstances: ----------------------------------------------
____ units if blood glucose is _____ to _____ mg/dl
____ units if blood glucose is _____ to _____ mg/dl
____ units if blood glucose is _____ to _____ mg/dl
____ units if blood glucose is _____ to _____ mg/dl
____ units if blood glucose is _____ to _____ mg/dl
Can student determine correct amount of insulin? Can student draw correct dose of insulin? FOR STUDENTS WITH INSULIN PUMPS:
Type of pump: ___________________________
Type of insulin in pump: _________________________________________________________________________ Type of infusion set: ____________________________________________________________________________ Insulin/carbohydrate ratio: _________________________________ Correction factor: ____________________ Student Pump Abilities/Skills:
Bolus correct amount for carbohydrates consumed Calculate and administer corrective bolus FOR STUDENTS TAKING ORAL DIABETES MEDICATIONS:
Type of medication: _____________________________________
Other medications: ______________________________________

Is student independent in carbohydrate calculations and management? □ Yes □ No Meal/Snack Other times to give snacks and content/amount: __________________________________________________
Preferred snack foods: _______________________________________________________________________
Foods to avoid, if any: _______________________________________________________________________
Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event):
A fast - acting carbohydrate such as ______________________________________ should be available at the site of
exercise or sports. Restrictions on activity, if any: _________________________________________________________
Student should not exercise if blood glucose level is below ___________________ mg/dl or above __________________
or if moderate to large urine ketones are present.
Blood glucose meter, blood glucose test strips, batteries for meter LOCATION OF SUPPLIES AT SCHOOL
Insulin pen, pen needles, insulin cartridges
This Diabetes Action Plan has been approved by:
Student’s Physician/Health Care Provider I give permission to the school nurse, trained diabetes personnel, and other designated staff members of St. Catherine School to perform and carry out the diabetes care tasks as outlined by this Diabetes Action Plan. I also consent to the release of the information contained in this Diabetes Action Plan to all staff members and other adults who have custodial care of my child and who may need to know this information to maintain my child’s health and safety. I also authorize the school nurse to discuss this Diabetes Action Plan and matters pertinent to this action plan with the above named health care provider. Acknowledged and received by: ____________________________________________________________________ ____________________________________________________________________


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