These are commonly used forms for the student with diabetes. Please call Nurse Kathy at 731-3817 to set up a meeting at the start of each school year or when your child is diagnosed with diabetes so that we can work together to set up an individualized plan for your child's care at school.
School Orders for Children with Diabetes
To be completed by doctor prior to the start of each school year or when the diagnosis is made and brought to the school nurse
Parent Delegation for Diabetes Care
To be signed by parent to permit nurse to train other school personnel as Diabetes Trained Persons
School Diabetes Care Plan by Parent
Used along with medical orders for diabetic student who uses injected insulin
School Diabetes Care Plan by Parent - Insulin Pump
Used along with medical orders for diabetic student who uses an insulin pump
Diabetic Care Plan Hyperglycemia (High blood sugar)
Filled out by parent to identify student's signs of hyperglycemia
Diabetic Care Plan Hypoglycemia (Low blood sugar)
Filled out by parent to identify student's signs of hypoglycemia
HIPAA Form
Permits your child's doctor to communicate with your school nurse to coordinate care
Physician's Orders
If your student has an insulin pump, please have the doctor complete the physician's order form allowing the nurse to change the pump site at your
request in the event the site fails.
School Orders for Children with Diabetes
To be completed by doctor prior to the start of each school year or when the diagnosis is made and brought to the school nurse
Parent Delegation for Diabetes Care
To be signed by parent to permit nurse to train other school personnel as Diabetes Trained Persons
School Diabetes Care Plan by Parent
Used along with medical orders for diabetic student who uses injected insulin
School Diabetes Care Plan by Parent - Insulin Pump
Used along with medical orders for diabetic student who uses an insulin pump
Diabetic Care Plan Hyperglycemia (High blood sugar)
Filled out by parent to identify student's signs of hyperglycemia
Diabetic Care Plan Hypoglycemia (Low blood sugar)
Filled out by parent to identify student's signs of hypoglycemia
HIPAA Form
Permits your child's doctor to communicate with your school nurse to coordinate care
Physician's Orders
If your student has an insulin pump, please have the doctor complete the physician's order form allowing the nurse to change the pump site at your
request in the event the site fails.