Blood Glucose And Insulin Procedures
________________________________ __________________________ Name of Student Grade/Teacher ________________________________ __________________________ 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.
________________________________ _____________ Student's Signature Date ________________________________ _____________ Nurse's Signature Date
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.
________________________________ _____________ Parent/Guardian Signature Date
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