Back to Diabetes Management at School Blood Glucose And Insulin Procedures

Blood Glucose And Insulin Procedures

________________________________   __________________________
Name of StudentGrade/Teacher
________________________________   __________________________
Name of PhysicianPhysician'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 SignatureDate
________________________________   _____________
Nurse's SignatureDate


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 SignatureDate

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