The Nursing Department of Central CUSD 301 provides nursing services that promote students ability to learn. Our goals are to:

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1 Date Dear (Parent / Guardian), The Nursing Department of Central CUSD 301 provides nursing services that promote students ability to learn. Our goals are to: o Assist students in learning how to take care of their health; o Promote a safe school environment; o Facilitate good control of a student s health condition so they are ready to learn. Diabetes can affect a student s ability to learn if it is not under good control. To help us meet these goals, the nursing staff works closely with school personnel, individual students with diabetes, their families and the student s health care provider. Each year we need to have the following information for your child: o Written diabetes management plan from your health care provider o Signed authorization from parent/guardian for medication and treatment at school o Authorization of parent/guardian to share information with school personnel o Parent / guardian permission to communication with the health care provider o Authorization from the health care provider, parent/guardian and student if the student is capable of independently managing any one of the following: glucose monitoring, monitoring and insulin administration, or an insulin pump. Enclosed you will find necessary documents and a summary of roles and responsibilities of school staff, student and family. Please review and provide all the needed paperwork to the school health office before the first day of school. For independent management, only one consent (of the three forms enclosed) is needed. Parents / guardians are encouraged to contact the nurse to arrange a mutually convenient time for the team to meet to review all aspects of your student s care at school. Please feel free to contact us with any questions or concerns. Respectfully, Central CUSD 301 Health Department Staff

2 Roles and Responsibilities Student Cooperate with school personnel and family in implementing the diabetes plan of care for school Observe all policies and procedures, including those related to blood and body fluid precautions and sharps disposal Maintain the CCUSD #301 Diabetes Daily Log (Appendix B) under the supervision and guidance of the nurse Seek adult help immediately when low or high blood glucose levels, equipment malfunctions, or any other problems are suspected Demonstrate competence in glucose monitoring and insulin administration. (This is contingent upon agreement of healthcare provider and parent) Monitor supplies, including those in health office and after-school kit and inform parent / guardian in a timely manner of supplies needing replenishment. Parents / Guardians Inform the school as soon as possible of all changes in management and supply school staff with written orders from the health care provider Facilitate communication between the school staff and health care providers Participate in care planning meetings at school By the first day of attendance, provide all necessary consents, healthcare provider orders, equipment and supplies Assume responsibility for the maintenance & calibration of all supplies, including necessary food, juice, snack items, glucose tabs, etc. Provide clear, concise calculations of carb counts or guidelines to promote healthy eating habits Assume responsibility for management and / or supervision during extracurricular activities Confirm that emergency contact information is current and accurate Promote self-sufficiency in diabetic management. All school personnel designated by the team will be responsible to: Participate in some level of training as determined by the team Collaborate & communicate with the student, family, administration and the team Respect the student s right to confidentiality and privacy Be aware that behavior changes could be a symptom of blood glucose changes Maintain a safe environment that meets the needs of the student with diabetes.

3 (Roles and Responsibilities continued) Diabetes Principal /Administrative Designee Provide leadership for all school personnel to ensure that all guidelines related to diabetes management at school are current and implemented Facilitate training of school personnel, in emergency care, in disaster preparedness and in individualized student health care Facilitate planning meetings and the development of care plans. Nurse Function under the scope of practice of the Illinois Nurse Practice Act Obtain and maintain current knowledge related to management of diabetes If desired, initiate and maintain a checklist to monitor that aspects of implementing care at school are completed Organize and facilitate planning meetings and the development of care plans Provide or arrange for training of school personnel and maintain documentation of completed training Supervise or oversee the completion of the CCUSD #301 Diabetes Daily Log Promote self-sufficiency in diabetic management and provide support as needed Act as a resource to all team members and maintain a resource file of publications Practice universal precautions and infection control procedures Retain supplies and Disaster Preparedness Kit in health office. Teachers Participate in development of care plans that fit the school day and optimize the student s ability to participate in the curriculum Know student-specific signs and symptoms along with appropriate interventions Promote self-sufficiency in care and provide support as needed Provide clear information to substitute teachers Comply with accommodations Understand that hypoglycemia can occur during and after physical activity so the student should not be left alone after any vigorous activity. Transportation Keep emergency plan for student and contact numbers, readily available on bus Provide clear information to substitute bus drivers. Food Service Personnel Provide nutritional information about school menus as requested Promote timely access to food and sufficient time to eat. (Adapted from the Nursing Guidelines for the Delegation of Care for Students with Diabetes in Florida Schools)

4 Care Plan - Healthcare Provider Orders - Med-A for Students with Diabetes Diabetes Care Plan for: (name of student) School: Effective Date of Plan: To be completed by the health care provider and reviewed with parents / guardians and other school staff as needed. Copies to be kept in the student s classroom(s) and in school records. Date of Birth: / / Grade: Team (MS): Physician s Name (please print) Office Address: Telephone: Fax: I. Blood Glucose Monitoring Target Range for blood glucose: mg/dl to mg/dl Type of blood glucose meter used by student: Usual times to test blood glucose: Times for additional checks (note all that apply): Before exercise After exercise When student exhibits symptoms of hyperglycemia When student exhibits symptoms of hypoglycemia Other (please specify): May / can student perform his / her own blood glucose test? (circle) Yes No Note any exceptions: II. Insulin Insulin/Carb Ratio (I:CR) units/ gms Fixed insulin lunch dose Correction Factor (CF) units per mg/dl over mg/dl Can parent adjust I:CR by + / - 1 to 5 grams (circle): Yes No A. INJECTABLE INSULIN to be given in school: Time Type Dosage Can student determine accurate / correct amount in insulin? (circle): Yes No Can student draw correct dosage of insulin? (circle): Yes No Can / may student give his / her own insulin injections? (circle): Yes No Note any exceptions: B. INSULIN PUMPS Type of pump: Basal Rate(s): Time Rate Is student competent regarding the pump and its use? Yes No Can student effectively troubleshoot problems (i.e., pump malfunction, ketosis) Yes No Note any exceptions:

5 (Care Plan/Order/Med A-Diabetes pg. 2 of 2) C. ORAL MEDICATIONS Type: Dose: Time: Other: Note any exceptions: III. Snacks and Meals Breakfast A.M. Snack Lunch P.M. Snack Food in class (e.g. party) E. Exercise and Sports Student should not exercise if BG below mg/dl above mg/dl Snack before exercise? Yes No Snack after exercise? Yes No Other Hypoglycemia (Low Blood Sugar) Student s usual symptoms of hypoglycemia: Glucagon: Treatment of hypoglycemia: Hyperglycemia (High Blood Sugar) Student s usual symptoms of hyperglycemia: Treatment of hyperglycemia: Circumstances when urine or blood ketones should be tested: Treatment of ketones: I believe is capable of self-managing: Blood glucose monitoring Insulin Injections Insulin Pump Management/Care Exceptions: HEALTHCARE PROVIDER SIGNATURE: DATE: Other Orders/Considerations: HEALTHCARE PROVIDER SIGNATURE DATE PARENT / GUARDIAN I give permission for my child to monitor / manage his or her diabetic care (initial) independently during school as ordered by his/her healthcare provider. I give permission for the school staff to administer the medication routine described in (initial) this document as ordered by his/her healthcare provider. Parent Signature Initials Date: Received by school representative: Date:

6 Mutual Agreement: Student Independent Performance of Blood Glucose Monitoring This agreement will be used if / when the physician and parent / guardian agree that a student with diabetes is capable of self management of his/her blood glucose monitoring at school. This agreement will be attached to the Individual Health Care Plan (IHP). This agreement has been designed to ensure student safety and well-being. Persons indicated below will assume designated responsibilities; each task should be initialed. Student: Date of Birth: STUDENT I agree to : follow my health care provider s orders use correct technique to check my blood glucose report hyperglycemia or hypoglycemia immediately keep written records, with the help of the nurse if needed seek help from school personnel if any problems should occur advise my parent / guardian when supplies need replenishment follow standard precautions to protect from blood borne pathogens. PARENT / GUARDIAN I agree to: ensure that my child possess necessary skills and maturity for independent monitoring of blood glucose provide necessary equipment within 24 hours, inform the school personnel of any changes in the student s health status, medications or treatment regimen. NURSE I agree to: review any blood glucose monitoring records supervise medication administration in response to blood glucose levels consult with student regularly contact parent / guardian or healthcare provider with any concerns. Student Signature: Initials: Date: Parent/Guardian Sign: Initials: Date: Nurse: Initials: Date:

7 Mutual Agreement: Student Independent Performance of Blood Glucose Monitoring and Insulin Administration This agreement will be used if / when the physician and parent / guardian agree that a student with diabetes is capable of self management of both glucose monitoring and insulin administration at school. This agreement will be attached to the Individual Health Care Plan (IHP). This agreement has been designed to ensure student safety and well-being. Persons indicated below will assume designated responsibilities; each task should be initialed. Student: Date of Birth: STUDENT I agree to : follow my health care provider s orders use correct technique to check my blood glucose determine insulin dose based on the healthcare provider orders report hyperglycemia or hypoglycemia immediately keep daily records, if agreed upon by parent/guardian and nurse notify nurse if blood glucose is out of target range 2x / week during school seek help from school personnel if any problems should occur advise my parent/guardian of any problems or if supplies are needed follow standard precautions to protect from blood borne pathogens never allow anyone else to access my supplies or medications. PARENT / GUARDIAN I agree to: ensure that my child possesses necessary skills & maturity for independent monitoring of blood glucose and administration of insulin provide necessary equipment within 24 hours, inform the school personnel of any changes in the student s health status, medications or treatment regimen. NURSE I agree to: review any blood glucose monitoring or insulin administration records supervise medication administration in response to blood glucose levels consult with student regularly contact parent / guardian or healthcare provider with any concerns. Student Signature: Initials: Date: Parent/Guardian Sign: Initials: Date: Nurse: Initials: Date:

8 Mutual Agreement: Student Independent Performance of Insulin Pump This agreement will be used if / when the physician and parent / guardian agree that a student with diabetes is capable of self management of his/her insulin pump. This agreement will be attached to the Individual Health Care Plan (IHP). This agreement has been designed to ensure student safety and well-being. Persons indicated below will assume designated responsibilities; each task should be initialed. Student: Date of Birth: STUDENT I agree to : follow my health care provider s orders program the pump deliver correct bolus based on glucose values, activity & food consumption report pump malfunctions, skin site problems, symptomatic hypo or hyper glycemia or any other problems to nurse, teacher or parent immediately keep daily records, if agreed upon by parent/guardian and nurse notify nurse if blood glucose is out of target range 2x / week during school seek help from school personnel if any problems should occur advise my parent/guardian of any problems or if supplies are needed follow standard precautions to protect from blood borne pathogens never allow anyone else to access my supplies or medications. PARENT / GUARDIAN I agree to: ensure that my child possesses necessary skills & maturity for independent monitoring of blood glucose and utilization of pump provide necessary equipment within 24 hours, inform the school personnel of any changes in the student s health status, medications or treatment regimen. NURSE I agree to: review any blood glucose monitoring or insulin administration records supervise medication administration in response to blood glucose levels consult with student regularly contact parent / guardian or healthcare provider with any concerns. Student Signature: Initials: Date: Parent/Guardian Sign: Initials: Date: Nurse: Initials: Date:

9 DISASTER PREPAREDNESS KIT RECOMMENDATIONS Supplies It is recommended that the parents provide a three-day supply of the following at the beginning of the school year: Blood sugar meter (with instructions) and meter strips or visual strips Ketone strips Insulin: may be stored in refrigerator but refrigerator may not be accessible during a disaster. Insulin at room temperature may begin to loose potency after one month. Label with date that it is brought to school and date when actually opened Insulin syringes Lancets Antiseptic wipes or wet wipes Small logbook to record insulin dose/blood sugar results Bedtime snack bar, such as Nite-bite, if used Low blood sugar reaction supplies: quick-acting sugar and carbohydrate / protein snack. Send enough supplies for two to three episodes Schools are generally prepared for inclement weather with food for one or two meals on hand. If a student needs specialized food, his or her parents should work with the healthcare provider and / or dietitian and the flood service personnel at school to plan for emergency situation It is suggested that the diabetes supplies be replaced during the winter holiday season. This way, what has been kept at school can be used before its expiration. It is important that supplies such as meter and all testing strips be kept at room temperature, as extreme heat or cold may impair function. (Taken from the Guidelines for Care of Students with Diabetes, Washington State, May 2005) Central Community School District #301

10 275 South St., P.O. Box 396, Burlington, IL Phone: Fax: AUTHORIZATION FOR RELEASE OF SCHOOL STUDENT RECORDS I,, parent legal guardian surrogate parent primary caretaker, authorize to release records checked PREVIOUS DISTRICT & SCHOOL NAME AND ADDRESS OR AGENCY below, regarding,, / /, STUDENT BIRTHDATE to:, ( NAME & TITLE PHONE ) AGENCY, STREET ADDRESS, CITY, STATE, ZIP CODE for the purpose of educational and / or individual healthcare planning. This consent is valid until / /, unless otherwise revoked by me in writing. RECORDS TO BE RELEASED The records released shall cover the dates of / / to / /. (Optional) PERMANENT RECORDS Student s Name, Address, DOB, Birthplace, Gender, Birth Certificate Parent s Name(s), Address(es) Attendance Records Accident Reports X Health Records (excluding mental health) Academic Transcript Honors/Awards received Participation in Extracurricular Activities) TEMPORARY RECORDS Class Schedule Disciplinary Information Test Scores: intelligence, aptitude, achievement levels Family Background Information X Special Education Records: IEP Psychological Evaluations Social Work Assessment Educational Evaluation & Reports X Medical/Nursing Records Speech, Physical or Occupational Therapy Evaluations/Reports Specialized Evaluations: psychiatric, audiological, vocational assessment Reports/Evaluations Received From INSTITUTION/AGENCY/INDEPENDENT PRACTITIONER Other: communication between staff. NOTE: Release of MENTAL HEALTH records requires completion of a consent form in compliance with the Mental Health and Developmental Disabilities Act, 740 ILCS 110. I understand that I have the right to INSPECT, COPY, and CHALLENGE the content of the school student records for which I am authorizing release. I also have the right to designate the school student records to be released or to identify specific portions of a school record to be released by this consent. Any such limitations have been noted above. AUTHORIZED SIGNATURE DATE NOTICE TO AGENT/PERSON RECEIVING RECORDS Under the provision of the Illinois School Student Records Act, 105 ILCS 10/6/(d) and the Federal Education Rights and Privacy Act, you may not redisclose any of the information received without first obtaining specific, written, consent conforming with these Acts. Unauthorized rerelease of this information could result in your inability to receive future educational records for a period of five years. ED v