Parent Consent And Licensed Healthcare Provider Authorization For Diabetes Management In School And School Sponsored Events Form

Parent Consent and Licensed Healthcare Provider Authorization

For Diabetes Management In School and School Sponsored Events

Individualized School Healthcare Plan (ISHP) and Standard Procedures Will Provide Details for Implementation

Pupil

DOB

School

Grade

Licensed Healthcare Provider’s Written Authorization: Please initial and check all boxes that apply

1. Blood Glucose Testing:

6. Licensed Health care provider verification: Student can perform the

following procedures (parent and school nurse must verify competency as well):

 Before am snack

 Blood glucose testing  Measuring insulin  Injecting insulin

 Before lunch

 Determining insulin dose  Independently operate insulin pump

 2 hours after lunch

 other: _____________________________________________

 2 hours after a correction dose

7. Insulin Orders (complete only if insulin is needed at school):

 For suspected Hypoglycemia

Brand Name and type:___________________________________

 At students discretion excluding suspected hypoglycemia

Administration times (fill in times only those that apply):

 Only at students discretion

 Breakfast  AM snack  Lunch  PM snack

 No blood glucose testing at school

 Other: _____________________________________________

Target range for blood glucose testing at school:____________

Insulin administration via:

2. Hypoglycemia-blood glucose less than 70:

 Self treatment of mild lows  Assistance for all lows  Provide extra

 Syringe  Insulin pump  Insulin pen

protein & carb snack after treating lows or feed snack/meal early (if scheduled

 Other: _____________________________________________

within the hour).

Insulin dose determined by (Check all that apply):

 Okay to use glucose gel inside check; even if unconscious

Food/bolus doses:

 Glucagon injection IM (for severe hypoglycemia): ___ 0.5mgm ___ 1mgm

 standard lunchtime dose: ______________________________

(Refer to attached “Algorithms for Blood Glucose Results” for summary of treatment

 Insulin to carbohydrate ratio:

procedures)

_____ # unit(s) insulin per _____ gms Carbohydrate

3.

Hyperglycemia

 If blood glucose> ______initiate insulin administration order

 Correction Calculation (complete only those that apply):

 If blood glucose> ______or exhibit symptoms of ketosis, check ketones.

Give _____ unit(s) for every _____ mg/dl above _____ mg/dl

•

 Check urine ketones

 Check blood ketones.

Decrease correction by _____ % unit(s) if PE or increased activity is

•

(Refer to attached “Algorithms for Blood Glucose Results” for summary of treatment

anticipated after correction dose, or last dose was given less than 2

hours before.

OR

procedures)

 Written on slide scale as follows:

4.

Meal Plan

Blood Glucose from ________to________=________Units

Snacks/Meals:  Mandatory  At student’s discretion

Blood Glucose from ________to________=________Units

 AM snack time: ________ PM snack time: ________

Blood Glucose from ________to________=________Units

 Lunch time: ____________ Other: ________________

Blood Glucose from ________to________=________Units

 Extra food allowed:  Parent’s discretion  Student’s discretion

 Add carb calculation insulin dose and correction calculation for total insulin

5. Exercise (Check and/or complete all that apply)

dose/bolus

Liquid and solid carb sources must be available before, during and after all exercise.

8. Bus Transportation:

No exercise if most recent blood glucose is <70.

 Blood glucose test not required prior to boarding bus.

 Eat ___gms CHO for vigorous exercise:

 Test blood glucose 10 to 20 minutes before boarding bus

 Before  Every 30 min. during,  After

Provide 15 gm glucose source if blood glucose is <___ mmg/dl

•

 No exercise when blood glucose is > ___ or ketones present

Provide care as follows:_____________________________________

•

Other Needs: Specify on physician stationary or prescription pad and attach.

Licensed Health Care Provider Authorization For Diabetes Management In School

My signature below provides authorization for the above written orders. I understand that all procedures will be implemented in accordance with state laws and regulations.

I understand that specialized physical health care services may be performed by unlicensed designated school personnel under the training and supervision provided by the

school nurse. This authorization is for a maximum of one year. If changes are indicated, I will provide new written authorization (may be faxed).

Licensed Healthcare Provider Name: _____________________________ Signature ____________________________ Date ______________ Phone______________

Address ______________________________________City _____________________Zip ____________

 I have instructed ___________________ in the proper way to use his/her medications. It is my professional opinion that________________ should be allowed to carry

)

(Child’s Name

(Child’s Name)

and use that medication by him/herself. ____ Licensed Healthcare Provider Initial

 I request that the School Nurse provide me with a copy of the completed Individualized School Healthcare Plan (ISHP).

Parent Consent for Diabetes Management In School

I (we) the undersigned, the parent(s)/guardian(s) of the above named pupil, request that the following specialized physical health care service for Management of Diabetes in

school be administered to my (our) child in accordance with state laws and regulations.

I (we) will:

1. Provide the necessary supplies and equipment

2. Notify the school nurse if there is a change in pupil health status or attending licensed healthcare provider.

3. Notify the school nurse immediately and provide new consent for any changes in licensed healthcare provider’s orders,

I (we) give consent for the school nurse to communicate with the licensed healthcare provider when necessary.

I (we) understand that I (we) will be provided a copy of my child’s completed Individual School Healthcare Plan. (ISHP)

Parent/Guardian Signature ______________________________________________________

Date ________________________

______________________________________________________

Date_________________________

Reviewed by School Nurse (Signature) ______________________________________ Date__________________