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		Diabetes Health Care Emergency Action Plan

Diabetes Health Care Emergency Action Plan

Student Information

Name: DOB: Grade:

Address:

Father/Guardian: Phone (home): Phone (work):

Mother/Guardian: Phone (home): Phone (work):

Other Emergency Contacts

Name: Relationship: Phone:

Name: Relationship: Phone:

Physician: Phone:

Hospital: Transport: [  ] Parent   [  ] Ambulance   [  ] Other

Emergency items to be left at school:     [  ] Glucose tablets
[  ] Snacks
[  ] Syringes
[  ] ________________ [  ] Blood glucose meter
[  ] Insulin
[  ] ________________
[  ] ________________

In the event of an insulin reaction, the procedure routinely followed at school is to give some form of sugar such as 1/2 carton of milk followed with crackers and peanut butter, 1/2 cup fruit juice or 1/2 cup non diet soda. If the student is unconscious, "911" is called.
I approve the above health care action plan as written. Yes _____ No _____
Please make the following changes to the health care action plan:

List other additional information or significant special health concerns of this student:

I give permission for emergency blood glucose testing by the school nurse using equipment I have provided. I understand that when the school nurse is not available for emergency blood glucose testing, the parent/guardian will be notified or "911" will be called. Yes _____ No _____
Additional directions regarding blood glucose testing:

Written and submitted by:   ________________________________    _____________

Nurse Date

Reviewed and signed:   ________________________________    _____________

Parent/guardian Date

________________________________    _____________

Student Date

________________________________    _____________

Physician Date

To be reviewed   _____________

Date

Healthcare plans should be revised according to child's specific needs, at least annually.
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Last Updated: Wednesday November 26, 2003 09:44:12
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Student Information
Name:	DOB:	Grade:
Address:
Father/Guardian:	Phone (home):	Phone (work):
Mother/Guardian:	Phone (home):	Phone (work):
Other Emergency Contacts
Name:	Relationship:	Phone:
Name:	Relationship:	Phone:
Physician:		Phone:
Hospital:	Transport: [ ] Parent [ ] Ambulance [ ] Other

Written and submitted by:	________________________________	_____________
	Nurse	Date

Reviewed and signed:	________________________________	_____________
	Parent/guardian	Date

	________________________________	_____________
	Student	Date

	________________________________	_____________
	Physician	Date

To be reviewed	_____________
	Date