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    NIAGARA CATHOLIC DISTRICT SCHOOL BOARD

    STUDENT DIABETES MANAGEMENT PLAN OF CARE  APPENDIX B Page 1
     


     
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    NIAGARA CATHOLIC DISTRICT SCHOOL BOARD

    STUDENT DIABETES MANAGEMENT PLAN  APPENDIX B Page 1
    Student Name
    		 
    School Year Completed
    		                   to                           
    1. STUDENT PROFILE and INFORMATION
    School Year Completed
    		to
    Student Name                                                                                      
    Birth Date
    		                         Age 00
    Current School                                                                                                      
    Current Grade
    		Grade OEN                             
    Teacher(s)                                                                                                   
    Parent/Guardian                                                                                                            
    Home Address                                                                                                       
    Preferred Phone
    		                                         
    Diabetes Type                                  
    Additional Medical Diagnosis/Diagnoses
    		                                                                             
    2. EMERGENCY CONTACTS
     
    Name
    Relationship to Student
    Preferred Phone
    Alternate Phone
    1
    		    
    2
    		    
    3
    		   
    IN CASE OF ILLNESS: Blood glucose/sugar levels can drastically fluctuate when a student with diabetes becomes ill (nausea, vomiting, and other flu-like symptoms). In the event of illness/symptoms at school, Parent/Guardian will be contacted. In the event Parent/Guardian is not reached by the preferred phone number listed above, the identified Emergency Contacts will be notified in order of priority listed above.  
    3. SUPPLIES / EMERGENCY KITS Parent: Provide supplies to school and maintain/refresh when low.

    School: Ensure kit is accessible at all times during school day; advise parent when supplies run low.
    Contents (Check all locations that apply)
    Student
    Classroom
    Office
    		Other Location
    Fast-acting sugars: Specify type of fast-acting sugars used
    ☐
    ☐
    		☐
    ☐                                       
    Blood glucose meter, test strips, lancing device/lancets
    ☐
    ☐
    		☐ ☐                                       
    Carbohydrate snack(s)
    ☐
    ☐
    		☐ ☐                                      
    Insulin pen, pen needles, insulin syringe, insulin cartridge
    ☐
    ☐
    		☐ ☐                                      
    Ketone strips/meter
    ☐
    ☐
    		☐ ☐                                     
    Extra batteries (for meter, pump, etc.)
    ☐
    ☐
    		☐ ☐                                      
    Sharps disposal container
    ☐
    ☐
    		☐ ☐                                     
    Glucagon (Expiry date: )
    ☐
    ☐
    		☐ ☐                                     
    Parent/Emergency names and contact information
    ☐
    ☐
    		☐ ☐                                    
    Continuous glucose monitoring system
    ☐
    ☐
    		☐ ☐                                     
    Other: If required
    ☐
    ☐
    		☐ ☐                                     


    4. BLOOD GLUCOSE/SUGAR (BG) MONITORING
    Student’s Independence Level:                                                                                                                             
    Support/Supervision provided by:                                                                                                                                                  
    Student’s target blood sugar (BG) range: 0.00 to 0.00 mmol/L Call parent if blood sugar is: Below 0.00 Above 00.00
    Glucose meter(s) location: ☐ Student ☐ Classroom ☐ Office ☐                                     
    Daily blood sugar monitoring schedule
    		 
    ☐   AM Break Time: AM/PM ☐   Before leaving school Time: AM/PM  
    ☐ Lunch Time: AM/PM ☐ Before physical activity  
    ☐ PM Break Time: AM/PM ☐ Other time(s): Time: AM/PM
    Home-School BG communication method:                                                                              
    Does the student use a continuous glucose monitoring (CGM) device? Choose   (If Yes or Sometimes, complete Section 8.)  

     
     
    5. MEALS and NUTRITION BREAKS
    Ensure student has their nutrition break and meals on time.

    Allow enough time for them to eat. No food sharing.
    Student’s Independence Level :                                                                                                                
    Nutrition break and meal times:                                                                                                                                                  
    ☐ Student requires food at end of day/dismissal.
    ☐ When treats or other food is provided in the classroom:                                                      
    ☐ Student has food restrictions (allergies, intolerances, etc.):                                                                   
    ☐ Carbohydrate counting/calculations and labeling carb count on food is the responsibility of Parents/Guardians.  

      6. PHYSICAL ACTIVITY and EXCURSIONS AWAY FROM SCHOOL*
    Student’s Independence Level :                                                                                                               
    Before physical activity:                                                                                                             
    Physical Activity Plan:
    1.  LOW: If BG is under               mmol/L, treat for low blood sugar.
    (If required)
    2.  If BG is between               mmol/L and               mmol/L, give a snack before physical activity
    3.  HIGH: If BG is between          mmol/L and            mmol/L, no snack is needed before physical activity
    For students with an insulin pump:                                                                                                                                                             
    *School and Home must determine an alternate plan for blood glucose/sugar monitoring and support

    (if student is not independently capable) for excursions away from school location or outside of the regular school day

    when LHIN-provided Nursing is not available.
     


    7. INSULIN ADMINISTRATION ☐ Student does not take insulin at school (Do not complete this section)
    Insulin administration method:                                                                                                   
    Insulin administered by:                                                                                                                     
    Insulin administration schedule
    ☐   AM Break Time: AM/PM ☐   PM Break Time: AM/PM
    ☐   Lunch Time: AM/PM ☐   Other Time: AM/PM  
     
    PUMP ROUTINE and MANAGEMENT PLAN
    		PEN/SYRINGE ROUTINE and MANAGEMENT PLAN
    ☐   Parent provides a bolus calculator Type of insulin used:                                                                           
    ☐   Pump is always programmed at home Insulin calculator/administrator:                                                 
    Insulin administrator identified above will: ☐   Parent labels food with number of carbohydrates and provides bolus calculator to select appropriate insulin dose based on BG reading and number of carbohydrates.
    1.   Check BG before student eats. The reading is:
    ☐   Sent to pump by the meter.
    		☐   Same as above, with dose calculated by glucose meter.
    ☐   Entered manually into the pump.
    		☐   Parent send set number of carbohydrates for each meal each day. Parent provides an appropriate tool to help select appropriate insulin dose based on student’s BG.
    2.   Enter the total number of carbohydrates to be eaten (provided by home)
    3.   Pump will calculate amount of insulin to be given. Press the button to accept and deliver the bolus.
    If BG is above mmol/L:
    		☐   Parent send different number of carbohydrates for each meal each day. Parent provides an appropriate tool to help select appropriate insulin dose based on student’s BG.
    ☐   Check ketones ☐   Call Parent(s)  
    ☐   Other:                                              

     
    8. CONTINUOUS GLUCOSE MONITOR (CGM) ROUTINE AND MANAGEMENT
    Student’s target blood sugar (BG) range 0.00 to 0.00 mmol/L Call parent if blood sugar is: Below 0.00 Above 00.00
    Student’s Independence Level :  

     *Excluding incidences of severe hypoglycemia     		                                                                                                                                     
    CGM Results are sent to: ☐   Insulin pump** ☐   Remote device ☐   Parent smart device
    ** ☐   Low Glucose Suspend is active on pump
    		** ☐   If LGC is active, threshold is set at mmol/L.
    Low BG Alarm is set at: mmol/L.

    Low BG alarm should be confirmed with a BG check. Respond as per Student Diabetes Emergency Action Plan (Appendix C).
    High BG Alarm is set at: mmol/L.

    High BG alarm should be confirmed with a BG check. Respond as per Student Diabetes Emergency Action Plan     (Appendix C).
    IN THE EVENT OF A CGM DEVICE MALFUNCTION, IMMEDIATELY CONTACT PARENT/GUARDIAN FOR INSTRUCTIONS.
    9. PARENT PRE-AUTHORIZATION and CONSENT
    Consent to release and share information*: I authorize and provide consent to school staff to use and/or share information in this plan for purposes related to the education, health, and safety of my child. This may include:


    1.  Displaying my child’s photograph and/or additional information on paper notices or electronic formats(s) so that staff, volunteers, and school visitors will be aware of my child’s medical condition

    2.  Communicating with bus operators

    3.  Sharing information in special circumstances to protect the health and safety of my child.
    Consent to transfer to hospital: I consent in advance to my child’s being transported to a hospital if required, based on the judgement of school staff. I also permit a staff member to accompany my child during transport. I agree that the school’s administrator or designate shall decide if an ambulance is to be called.
    Consent to treatment: I am aware that school staff are not medical professionals and perform all aspects of this plan to the best of their abilities and in good faith. I approve of the management steps and responses outlined in this care plan.
    Consent for annual review (Appendix D): I am aware that school staff will request my involvement in an annual review of this management plan, and when requirements change significantly, they will request my involvement in completing a new plan.
    10. AUTHORIZATION and SIGNATURES
    Parent/Guardian (Print):
    Parent/Guardian Signature(s):
    Date Signed:
    School Administrator (Print):
    School Administrator Signature:
    Date Signed:
    Health Care Provider (Print):
    Health Care Provider Signature:

     (optional)
    Date Signed:
    		 

     

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    *This information is being collected pursuant to the provisions of the Municipal Freedom of Information and Protection of Privacy Act and under the Authority of the Education Act, and will be used by Student Support. Questions about this collection should be directed to the Superintendent of Education – Student Support, Niagara Catholic District School Board, 427 Rice Road, Welland, Ontario L3C 7C1, 905-735-0240.