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 (Updated May 2004)

Page A-9 Draft HIPAA-Compliant Authorization for Exchange of Health & Education Information - Sample
Downloadable Word Document --- pdf (New May 2004)

Page A-10 Draft HIPAA-Compliant Authorization for Release of Health Information - Sample
Downloadable Word Document --- pdf (New May 2004)

Page A-11 Prescription Medication Order and Permission to Administer Medication and to Test Blood Sugar Form
Downloadable Word Document --- pdf

Page A-12 Sample Letter to Health Care Provider Regarding Health Care Plan
Downloadable Word Document --- pdf

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

Page A-15 Health Services Department Emergency Plan – Diabetes (Sample #2)
Downloadable Word Document --- pdf (Updated May 2004)

Page A-16 Staff Training Record
Downloadable Word Document --- pdf (Updated May 2004)

Pages A-17 Blood Glucose and Insulin Procedures
Downloadable Word Document --- pdf

Page A-19 Health Services Blood Glucose Record
Downloadable Word Document --- pdf

Pages A-21 to A-22 504 Dietary Plan - Sample
Downloadable Word Document --- pdf (Updated May 2004)

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 (Updated June 2006)

Pages A-63 to A-64 Appendix E.4 Transportation Plan for Student With Special Health Care Needs
Downloadable Word Document --- pdf (Updated June 2006)

Page A-65 Appendix E.5 Section 504 Accommodation Plan
Downloadable Word Document --- pdf (Updated June 2006)

Pages A-69 to A-72 Appendix E.7 Individualized Healthcare Action Plan
Downloadable Word Document --- pdf  (Updated June 2006)

Page A-75 Appendix E.9 Sample Letter to Physician Regarding Healthcare Action Plan
Downloadable Word Document -- pdf (Updated June 2006)

Pages B-1 Pathophysiology of Diabetes pdf (Updated May 2004)

Pages C-1 to C-2 Nutrition Guidelines for Diabetes pdf (Updated May 2004)

Pages C-3 to C-4 Eating Healthy with the Diabetes Food Pyramid pdf

Page C-5 The Diabetes Food Pyramid pdf (Updated June 2006)

Pages C-6 to C-8 Classroom Snacks and Snack Substitutions pdf (Updated May 2004)

Pages C-9 to C-11 Eating Disorders and Diabetes pdf

Pages C-13 to C-14 504 Dietary Plan - Sample
Downloadable Word Document --- pdf (Updated May 2004)

Page D-1 Exercise and Diabetes pdf (Updated May 2004)

Page D-2 Additional Food for Activity pdf (Updated May 2004)

Pages D-3 to D-4 Exercise Safety Tips pdf (Updated May 2004)

Page E-4 Injection Sites pdf

Page E-5 Insulin Action Times pdf (Updated May 2004)

Pages E-7 to E-8 Insulin Delivery Systems pdf

Pages E-9 to E-10 Insulin Pumps in the School Setting pdf

Pages E-11 to E-14 Guidelines for Troubleshooting Insulin Pumps in the School pdf (New June 2003)

Page E-15 Disposing of Sharps Safely pdf

Pages E-17 to E-18 Oral Agents for Type 2 Diabetes pdf (Updated May 2004)

Pages E-19 to E-20 Effects of Over-the-Counter and Prescription Medications on Diabetes Control pdf

Pages F-3 to F-4 Recommended Guidelines for Blood Glucose Control pdf (Updated May 2004)

Pages F-7 to F-8 Treatment of Low Blood Sugars pdf (Updated May 2004)

Pages F-9 to F-10 Diabetes: Low Blood Sugar Emergencies pdf

Page F-11 Hypoglycemia - English pdf

Page F-12 Hipoglicemia - Spanish pdf

Page F-13 Hyperglycemia - English pdf

Page F-14 Hiperglicemia - Spanish pdf

Page F-15 What is Glucagon? pdf

Page F-16 Treatment of High Blood Sugars pdf (Updated May 2004)

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

Page G-3 Health Services Department Emergency Plan – Diabetes (Sample #2) (duplicate of page A-15)
Downloadable Word Document --- pdf (Updated May 2004)

Page G-5 Hypoglycemia (Low Blood Sugar) Quick Reference Emergency Planning Tool
Downloadable Word Document --- pdf (New May 2004)

Page G-6 Hyperglycemia (High Blood Sugar) Quick Reference Emergency Planning Tool
Downloadable Word Document --- pdf (New May 2004)

Page H-3 Standards of Clinical Care for Children pdf (Updated June 2003)

Pages I-1 to I-4 Local and National Resources pdf (Updated June 2006)

Pages I-5 to I-6 Children’s Hospitals & Facilities pdf (Updated June 2006)

Page I-7 American Diabetes Association Wizdom Kit pdf (Updated June 2006)

Page I-9 Letter from Juvenile Diabetes Research Foundation pdf

Pages I-11 to I-12 Famous People With Diabetes pdf

Page I-13 Types of Insulins pdf (Updated May 2004)
 

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