Maryland State Management Of Diabetes At School/order Form - 2004
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3Maryland State Management of Diabetes at School/Order Form
This order is valid only for the Current School Year: _______(including summer session)
Student: ____________________________________________________
DOB: ________________________
School:______________________________________________________
Grade: _______________________
CONTACT INFORMATION
Parent/Guardian:
Home Phone:
Work:
Cell/pager:
__________________________
__________________
_______________
________________
Parent/Guardian:
Home Phone:
Work:
Cell/pager:
__________________________
__________________
_______________
________________
Other Emergency Contact:
_____________________________________________________________________
Insulin Orders (complete only if insulin is needed at school):
1. Insulin administration via:
Other
Syringe and vial
Insulin pen
Insulin pump
Insulin pump
Type of pump:
Basal rates:
2. Insulin Before Lunch/Meals:
Name of Insulin: _____________________
Routine lunchtime dose: _____________
Per sliding scale as follows:
Meals
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Blood Glucose
to
give
units
Calculated insulin dose (add carbohydrate coverage and correction dose for total insulin dose):
Carbohydrate Coverage:
Insulin to carbohydrate ratio
Give ________ # unit(s) insulin per______gms carbohydrate.
Correction:
Give ________ # unit(s) insulin per______ mg/dl of glucose above ________ mg/dl
Subtract _______ # units for every _______ mg/dl of glucose below _______mg/dl
Insulin may be given after lunch if ________________________________________
3. Other times insulin may be given:
Snack:
Calculated as above.
Snack:
Dose: ___________
Blood Glucose
Give:
Ketones:
If ketones are ____________________ Give/Add: _________unit(s)
units
If ketones are ____________________ Give/Add: _________unit(s)
units
units
Health Care Provider Authorization for Management of Diabetes in School
My signature below provides authorization for the above written orders. This authorization is for a maximum of one school year. If
changes are indicated, I will provide new written authorization, which may be faxed.
Health Care Provider Name:
Signature:
(original or stamped signature) *Sign both sides.
_________________________
_______________________________
Address:
City:
Zip:
________________________________
__________________
__________
Phone:
Fax:
Date:
_______________________
_______________
___________
Use for Prescriber's Address Stamp
Parent Consent for Management of Diabetes at School
I (We) request designated school personnel to administer the medication and treatment orders as prescribed above. I agree
1. To provide the necessary supplies and equipment
2. To notify the school nurse if there is a change in the student’s diabetes management or health care provider.
I authorize the school nurse to communicate with the health care provider as necessary.
Parent/Guardian Signature
Date
_____________________________________________________
____________________ *Sign both sides.
Date
_______________________________________________________________
_________________________
Order reviewed and signed by School Nurse (per local policy):
Date:
MSDE6/04
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