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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:  ________________________________   _____________
 NurseDate
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Reviewed and signed:  ________________________________   _____________
 Parent/guardianDate
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 ________________________________   _____________
 StudentDate
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 ________________________________   _____________
 PhysicianDate
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To be reviewed  _____________
 Date

Healthcare plans should be revised according to child's specific needs, at least annually.

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Last Updated: Thursday February 27, 2014 19:28:21
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