children with DIABETES - Blood Glucose And Insulin Procedures

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		Blood Glucose And Insulin Procedures

Blood Glucose And Insulin Procedures

________________________________    __________________________

Name of Student Grade/Teacher

________________________________    __________________________

Name of Physician Physician's Phone Number

Medication Dose Time

Monitoring Blood Glucose and Administering Insulin

  Yes     No

Diabetes checklist returned

Demonstrates correct use of blood glucose meter

States proper time blood for glucose monitoring

Demonstrates documentation of blood glucose monitoring

Demonstrates knowledge of self-administration of insulin

States proper time for administration of insulin

Follows appropriate procedure for disposal of supplies

Carries treatment for insulin reactions

Agrees to seek assistance from school personnel as needed

If the student does/does not demonstrate meeting the above specified responsibilities, the privilege of monitoring blood glucose and self-administration of insulin will/will not be allowed.

________________________________    _____________

Student's Signature Date

________________________________    _____________

Nurse's Signature Date

Comments:
_______________________________________________________________________

_______________________________________________________________________
My child will be responsible for carrying this medication and will self-administer. My child agrees to follow the district's procedures concerning the handling and administration of this medication.

________________________________    _____________

Parent/Guardian Signature Date

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Last Updated: Wednesday November 26, 2003 09:44:12
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________________________________	__________________________
Name of Student	Grade/Teacher

________________________________	__________________________
Name of Physician	Physician's Phone Number

Yes	No
		Diabetes checklist returned
		Demonstrates correct use of blood glucose meter
		States proper time blood for glucose monitoring
		Demonstrates documentation of blood glucose monitoring
		Demonstrates knowledge of self-administration of insulin
		States proper time for administration of insulin
		Follows appropriate procedure for disposal of supplies
		Carries treatment for insulin reactions
		Agrees to seek assistance from school personnel as needed

________________________________	_____________
Student's Signature	Date

________________________________	_____________
Nurse's Signature	Date

________________________________	_____________
Parent/Guardian Signature	Date