504 FOR CHILD’S NAME SCHOOL YEAR SCHOOL YEAR JUVENILE

504 FOR CHILD’S NAME SCHOOL YEAR SCHOOL YEAR JUVENILE
ACCIDENT REPORT CHILD’S NAME DATE OF ACCIDENT TIME OF
ADHD RATING SCALEIV CHHHC HOME VERSION CHILD’S NAME GENDER

ALL ABOUT ME CHILD’S NAME ……………… AGE ……………… TODAY’S
ARRIVAL AND DISMISSAL ROUTINES 20192020 CHILD’S NAME GRADE TEACHER’S
AUDITORY SKILLS CHECKLIST CHILD’S NAME BIRTH DATE PERSON REVIEWING

504

For <child’s name>

<School year> School Year


Juvenile Diabetes or Type 1 Diabetes


  1. <Child> wears an Insulin Pump for his diabetes. <Child> must be dosed for all food and sugary drinks taken in accordance with the dosage chart provided by the parents. (Parents may change dosage chart at any time) Students will be instructed not to touch the pump or it’s tubing at any time for any reason.


  1. Parents shall provide meter, test strips, lancing device and lancets, ketone sticks, gloves, sharps container for disposal, emergency Glucagon, and pump supplies, syringes and insulin for emergency dosing for the nurses office. For the classroom, parents shall provide meter, test strips, lancing device and lancets, gloves, sharps container for disposal, glucose tabs and snacks for treating hypoglycemia. The classroom supplies will be in the same room (or on the playground) with <child> at any time. (Lincoln Public Schools will allow snacks in the classroom, but if the child is not capable of testing themselves with Teacher/Adult interpreting numbers, then the only supplies needed for the classroom would be snacks and glucose tabs and/or gel) It will be taken on field trips, fire alarms/drills, tornado alarms/drills, or at any other time <child> leaves any area.


  1. Lancet will be changed in the lancet device once daily, with the used lancet being placed in the sharps container.


  1. <Child> will be allowed in-room testing. (<District> Public Schools only allows this if the child is capable of conducting the test himself. Teacher/Adult must interpret the numbers. Otherwise the district requires testing in the Nurses office.) Testing must be done at anytime child is acting low, see chart, or complains he feels low. All teachers <Child> comes in contact with will be trained in this testing. <Child> is capable of testing himself with supervision, with adult interpreting blood glucose numbers. If the numbers require, correction or snacks will be given in accordance with dosage chart provided. Numbers and any corrective action will be recorded in log book provide. Log book will come home and return daily to school with <child>. The goal is to minimize disruptions in <child’s> regular school schedule and minimize time away from the classroom.


  1. Blood sugar testing must be done before any testing and fall in normal ranges, <Blood Glucose range provided by Doctor>. If numbers are not in range, testing must be held off until corrections have been made according to provided instructions. (Parents may change these instructions at any time.) He will be given time for blood sugar correction to take place without penalty. He will be allowed the same time allotted to the other students for the testing.


  1. Blood sugar must be tested before gym class, and needs to have numbers from <Blood Glucose range provided by Doctor> for participation. If he is below the 125, a snack must be given according to instructions. After snack, he may participate as normal. If he is over 240, test for ketones. If no ketones are present, he may participate as normal.


  1. If <child> behaves in a manner that is out of character (i.e., disrespectful/ belligerent/ defiant; hard time staying in his seat; sleepy, lethargic) then his blood sugar must immediately be taken. Blood sugar level should fall within normal range before any disciplinary action is taken.


  1. <Child> will be allowed unlimited access to water and the bathroom.


  1. <Child> will be allowed snacks anytime and anywhere as blood sugars dictate.


  1. <Child> will not be penalized in anyway for missing school or tardiness related to his diabetes (medical appointments, illness, or time necessary to maintain blood glucose control). <Child>’s diabetes will not prevent him from participating in any class activity or field trips.


  1. Parents must be contacted for any of the following reasons: <Child’s> infusion set comes out (insulin pump no longer connected to his body), his pump alarms and cannot be remedied, his blood sugar is less that 50, his blood sugar is less than 75 on two consecutive readings, his blood glucose exceeds 300, his blood glucose exceeds 250 on two consecutive readings, if ketones are present.


  1. Glucagon will be administered in accordance with Doctors orders.


  1. Parents will provide a mandatory teaching session to homeroom teacher, specials teachers, Nurse and Para, and all other staff deemed appropriate. Parents will review this instruction at semesters end. A copy of the health care plan, and instruction sheets will be provided for each room by parents.


Emergency Contacts


Parents <Name> home work cell

<Name> home work cell


Other Emergency Contact <Name> home work cell


Doctors’ Numbers


Pediatrician <Dr. Name> office

Endocrinologist <Dr. Name> office


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Tags: school year, missing school, school, child’s, juvenile