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Name of Student Grade/Teacher
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Name of Physician Physician’s Phone Number
Medication Dose Time

Monitoring Blood Glucose and Administering Insulin

  Yes   No
Diabetes checklist returned
Demonstrates correct use of blood glucose meter
States proper time blood for glucose monitoring
Demonstrates documentation of blood glucose monitoring
Demonstrates knowledge of self-administration of insulin
States proper time for administration of insulin
Follows appropriate procedure for disposal of supplies
Carries treatment for insulin reactions
Agrees to seek assistance from school personnel as needed

If the student does/does not demonstrate meeting the above specified responsibilities, the privilege of monitoring blood glucose and self-administration of insulin will/will not be allowed.

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Student’s Signature Date
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Nurse’s Signature Date

Comments:
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My child will be responsible for carrying this medication and will self-administer. My child agrees to follow the district’s procedures concerning the handling and administration of this medication.

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Parent/Guardian Signature Date