Diabetes Management in the School Setting
Forms and Handouts

The forms and handouts listed below have been pulled from the manual sections and are provided individually for your convenience.  The Downloadable Word Documents can be modified to suit your school’s specific needs. The PDF documents allow easy access to print the forms and handouts contained in the manual.

Pages A-5 to A-8 Diabetes Health History Form and Management Planning Tool
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-9 Draft HIPAA-Compliant Authorization for Exchange of Health & Education Information - Sample
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-10 Draft HIPAA-Compliant Authorization for Release of Health Information - Sample
Downloadable Word Document --- pdf(Reviewed August 2009)

Page A-11 Prescription Medication Order and Permission to Administer Medication and to Test Blood Sugar Form
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-12 Sample Letter to Health Care Provider Regarding Health Care Plan
Downloadable Word Document --- pdf (Reviewed August 2009)

Pages A-13 to A-14 Emergency Action Plan - Diabetes Health Care (Sample #1)
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-15 Health Services Department Emergency Plan – Diabetes (Sample #2)
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-16 Staff Training Record
Downloadable Word Document --- pdf (Updated August 2009)

Pages A-17 Blood Glucose and Insulin Procedures
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-19 Health Services Blood Glucose Record
Downloadable Word Document --- pdf (Reviewed August 2009)

Pages A-21 to A-22 504 Dietary Plan - Sample
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-27 Individualized Health Plan (IHP) - Blank Form
Downloadable Word Document --- pdf

Page A-61 Appendix E.3 Emergency Action Plan – Sample
Downloadable Word Document --- pdf (Reviewed August 2009)

Pages A-63 to A-64 Appendix E.4 Transportation Plan for Student With Special Health Care Needs
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-65 Appendix E.5 Section 504 Accommodation Plan
Downloadable Word Document --- pdf (Reviewed August 2009)

Pages A-69 to A-72 Appendix E.7 Individualized Healthcare Action Plan
Downloadable Word Document --- pdf (Reviewed August 2009)

Page A-75 Appendix E.9 Sample Letter to Physician Regarding Healthcare Action Plan
Downloadable Word Document -- pdf (Reviewed August 2009)

Pages B-1 Pathophysiology of Diabetes pdf (Reviewed August 2009)

Pages C-1 to C-2 Nutrition Guidelines for Diabetes pdf (Reviewed August 2009)

Pages C-3 to C-4 Eating Healthy with the Diabetes Food Pyramid pdf (Reviewed August 2009)

Page C-5 The Diabetes Food Pyramid pdf (Reviewed August 2009)

Pages C-6 to C-8 Classroom Snacks and Snack Substitutions pdf (Reviewed August 2009)

Pages C-9 to C-11 Eating Disorders and Diabetes pdf (Reviewed August 2009)

Pages C-13 to C-14 504 Dietary Plan - Sample
Downloadable Word Document --- pdf (Reviewed August 2009)

Page D-1 Exercise and Diabetes pdf (Reviewed August 2009)

Page D-2 Additional Food for Activity pdf (Updated September 2009)

Pages D-3 to D-4 Exercise Safety Tips pdf (Reviewed August 2009)

Page E-4 Injection Sites pdf (Reviewed August 2009)

Page E-5 Insulin Action Times pdf (Reviewed August 2009)

Pages E-7 to E-8 Insulin Delivery Systems pdf (Reviewed August 2009)

Pages E-9 to E-10 Insulin Pumps in the School Setting pdf (Reviewed August 2009)

Pages E-11 to E-14 Guidelines for Troubleshooting Insulin Pumps in the School pdf (Reviewed August 2009)

Page E-15 Disposing of Sharps Safely pdf (Reviewed August 2009)

Pages E-17 to E-18 Oral Agents for Type 2 Diabetes pdf (Reviewed August 2009)

Pages E-19 to E-20 Effects of Over-the-Counter and Prescription Medications on Diabetes Control pdf (Reviewed August 2009)

Pages F-3 to F-4 Recommended Guidelines for Blood Glucose Control pdf (Reviewed August 2009)

Pages F-7 to F-8 Treatment of Low Blood Sugars pdf (Reviewed August 2009)

Pages F-9 to F-10 Diabetes: Low Blood Sugar Emergencies pdf (Reviewed August 2009)

Page F-11 Hypoglycemia - English pdf (Reviewed August 2009)

Page F-12 Hipoglicemia - Spanish pdf (Reviewed August 2009)

Page F-13 Hyperglycemia - English pdf (Reviewed August 2009)

Page F-14 Hiperglicemia - Spanish pdf (Reviewed August 2009)

Page F-15 What is Glucagon? pdf (Reviewed August 2009)

Page F-16 Treatment of High Blood Sugars pdf (Reviewed August 2009)

Pages G-1 to G-2 Emergency Action Plan - Diabetes Healthcare (Sample #1) (duplicate of pages A-13 to A-14)
Downloadable Word Document --- pdf (Reviewed August 2009)

Page G-3 Health Services Department Emergency Plan – Diabetes (Sample #2) (duplicate of page A-15)
Downloadable Word Document --- pdf (Reviewed August 2009)

Page G-5 Hypoglycemia (Low Blood Sugar) Quick Reference Emergency Planning Tool
Downloadable Word Document --- pdf (Updated August 2009)

Page G-6 Hyperglycemia (High Blood Sugar) Quick Reference Emergency Planning Tool
Downloadable Word Document --- pdf (Updated August 2009)

Page H-3 Standards of Clinical Care for Children pdf (Updated September 2009)

Pages I-1 to I-4 Local and National Resources pdf (Updated September 2009)

Pages I-5 to I-6 Children’s Hospitals & Facilities pdf (Updated September 2009)

Page I-7 American Diabetes Association Wizdom Kit pdf (Reviewed August 2009)

Page I-9 Letter from Juvenile Diabetes Research Foundation pdf (Reviewed August 2009)

Pages I-11 to I-12 Famous People With Diabetes pdf (Reviewed August 2009)

Page I-13 Types of Insulins pdf (Reviewed August 2009)
 

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