Student Information
Name: DOB: Grade:
Father/Guardian: Phone (home): Phone (work):
Mother/Guardian: Phone (home): Phone (work):
Other Emergency Contacts
Name: Relationship: Phone:
Name: Relationship: Phone:
Physician: Phone:
Hospital: Transport: [ ] Parent [ ] Ambulance [ ] Other

Emergency items to be left at school: [ ] Glucose tablets
[ ] Snacks
[ ] Syringes
[ ] ________________ [ ] Blood glucose meter
[ ] Insulin
[ ] ________________
[ ] ________________

In the event of an insulin reaction, the procedure routinely followed at school is to give some form of sugar such as 1/2 carton of milk followed with crackers and peanut butter, 1/2 cup fruit juice or 1/2 cup non diet soda. If the student is unconscious, “911” is called.

I approve the above health care action plan as written. Yes _____ No _____

Please make the following changes to the health care action plan:

List other additional information or significant special health concerns of this student:

I give permission for emergency blood glucose testing by the school nurse using equipment I have provided. I understand that when the school nurse is not available for emergency blood glucose testing, the parent/guardian will be notified or “911” will be called. Yes _____ No _____

Additional directions regarding blood glucose testing:

Written and submitted by: ________________________________ _____________
Nurse Date
Reviewed and signed: ________________________________ _____________
Parent/guardian Date
________________________________ _____________
Student Date
________________________________ _____________
Physician Date
To be reviewed _____________

Healthcare plans should be revised according to child’s specific needs, at least annually.