- Diabetes Treatments

SAMPLE SECTION 504 PLAN
The attached sample Section 504 Plan was developed by the American Diabetes Association ADA and the Disability Rights Education and Defense Fund, Inc DREDF For further information, see the ADA Position Statement, Diabetes Care in the School and Day Care Setting Diabetes Care, Volume 27, Supplement 1, January 2004 and National Diabetes Education Programs Helping the Student with Diabetes Succeed: A Guide For School Personnel June 2003

Section 504 Plan for ___________________
School ________________________ School Year: _________________

______________________________
Students Name

________________
Birth Date

_____
Grade

Diabetes
Disability

____________________________________ Homeroom Teacher

______________ Bus Number

BACKGROUND
The student has type ____ diabetes Diabetes is a serious, chronic disease that impairs the bodys ability to use food Insulin, a hormone produced by the pancreas, helps the body convert food into energy In people with diabetes, either the pancreas doesnt make insulin or the body cannot use insulin properly Without insulin, the bodys main energy source glucose cannot be used as fuel Rather, glucose builds up in the blood
Over many years, high blood glucose levels can cause damage to the eyes, kidneys, nerves, heart and blood vessels Research has shown that these problems can be greatly reduced or delayed by keeping blood glucose levels near normal The majority of school-aged youth with diabetes have type 1 diabetes People with type 1 diabetes do not produce insulin and must receive insulin through either injections or an insulin pump Insulin taken in this manner does not cure diabetes and may cause the students blood glucose level to become dangerously low Type 2 diabetes, the most common form of the disease typically afflicting obese adults, has been shown to be increasing in youth This may be due to the increase in obesity and decrease in physical activity in young people Students with type 2 diabetes may be able to control their disease through diet and exercise alone or may require oral medications and/or insulin injections Neither insulin nor other medications are cures for diabetes; they only help control the disease All people with type 1 and type 2 diabetes must carefully balance food, medications, and activity level to keep blood glucose levels as close to normal as possible Low blood
glucose hypoglycemia is the most common health emergency for students with diabetes It occurs when the body gets too much insulin, not eating enough, a delayed meal or snack, or more than usual amount of exercise Symptoms of mild to moderate hypoglycemia include tremors, sweating, lightheadedness, irritability, confusion and drowsiness A student with this degree of hypoglycemia will need to promptly ingest carbohydrates and may require assistance Severe hypoglycemia, which is rare, may lead to unconsciousness and convulsions and can be life threatening if not treated promptly

High blood glucose hyperglycemia occurs when the body gets too little insulin, food is not covered by insulin or too little exercise; it may also be caused by stress, injury or an illness such as a cold The most common symptoms of hyperglycemia are thirst, frequent urination, fatigue, and blurry vision If left untreated, hyperglycemia can lead to a serious condition called diabetic ketoacidosis DKA characterized by nausea, vomiting and a high level of ketones in the urine For students using insulin infusion pumps, lack of insulin supply may lead to DKA in several hours DKA can be life-threatening and,
thus, requires immediate medical attention Accordingly, for the student to avoid the serious short and long term complications of blood sugar levels that are either too high or too low, this Section 504 Plan Plan, and the accompanying Diabetes Medical Management Plan DMMP, must be carefully followed and strictly adhered to by responsible school personnel To facilitate the appropriate care of the student with diabetes, school and day care personnel must have an understanding of diabetes and be trained in its management and in the treatment of diabetes emergencies Knowledgeable trained personnel are essential if the student is to avoid the immediate health risks of low blood glucose and to achieve the metabolic control required to decrease risks for later development of diabetes complications

OBJECTIVES/GOALS OF THIS PLAN
Both high blood sugar levels and low blood sugar levels affect the students ability to learn as well as seriously endangering the students health Blood glucose levels must be maintained in the ________________ range for optimal learning and testing of academic skills The student has a recognized disability, type __ diabetes, that requires the accommodations and
modifications set out in this plan to ensure that the student has the same opportunities and conditions for learning and academic testing as classmates, with minimal disruption of the students regular school schedule and with minimal time away from the classroom Steps to prevent hypoglycemia and hyperglycemia, and to treat these conditions if they occur, must be taken in accordance with this Plan and with the students Diabetes Medical Management Plan, which is attached to this Section 504 Plan and incorporated into it

REFERENCES
School accommodations, diabetes care, and other services set out by this Plan and the students Diabetes Medical Management Plan will be consistent with the information and protocols contained in the following documents: American Diabetes Association Position Statement Care of Children with Diabetes in the School and Day Care Setting, Diabetes Care, Volume 27, Supplement 1, January 2004

National Diabetes Education Program Helping the Student with Diabetes Succeed: A Guide for
School Personnel, June 2003

DEFINITIONS USED IN THIS PLAN
1 Diabetes Medical Management Plan DMMP: A plan that describes the diabetes care regimen and identifies the health care
needs of — and services to be provided to — a student with diabetes This plan is developed and approved by the students personal health care team and family A DMMP is useful in addressing the requirements of applicable federal laws Under Section 504, it is the
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schools responsibility to ensure the prompt development of a 504 plan for students with diabetes who need assistance to receive proper diabetes care while at school The assistance provided at school must be consistent with the orders of the students personal health care provider Schools must do outreach to the parents and childs health care provider if a DMMP or orders are not submitted by the family 2 Quick Reference Emergency Plan: A plan that provides school personnel with essential information on how to recognize and treat hypoglycemia and hyperglycemia 3 Trained Diabetes Personnel TDP: Non-medical school personnel who have basic diabetes knowledge and have received training in diabetes care, including the performance of blood glucose monitoring, insulin and glucagon administration, recognition and treatment of hypoglycemia and hyperglycemia, and performance of ketone checks This training should include the following
content based on current standards of care for children and youth with diabetes recommended by the American Diabetes Association: General overview of typical health care needs of a student with diabetes and how these needs are addressed in the students written care plans Explanation/overview of type 1 and type 2 diabetes The effect of balancing insulin, food, and exercise upon a students blood glucose levels Procedures for routine care of individual students, including blood glucose monitoring, insulin administration, urine ketone testing, and recording results Signs and symptoms of hypoglycemia and hyperglycemia and the short- and long-term risks of these conditions Treatment of hypoglycemia and hyperglycemia Insulin administration Glucagon administration Managing nutrition and exercise in the school setting Tools, supplies, and equipment require for diabetes care and their storage Legal rights and responsibilities of schools and parents/guardians

ACADEMIC-RELATED ACCOMMODATIONS
1 HEALTH CARE SUPERVISION 11 At least _______ adult staff members will receive training to be Trained Diabetes Personnel TDP, and TDP will be available at all times during school hours, during
extracurricular activities, and on field trips when the school nurse is not available to oversee the students health care in accordance with this Section 504 Plan and the students Diabetes Medical Management Plan, including performing or overseeing insulin administration, blood glucose monitoring, ketone checks, and responding to hyperglycemia and hypoglycemia including administering glucagon A written back-up plan will be implemented to ensure that a TDP is available in the event that the school nurse is unavailable 12 Any staff member who has primary care for the student at any time during school hours, extracurricular activities, or during field trips, and who is not a TDP, shall receive training that
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will include a general overview of diabetes and typical health care needs of a student with diabetes, recognition of hypoglycemia and hyperglycemia as described by the students Quick Reference Plan, and identity of school nurses and TDP and how to contact them for help Primary care means that the staff member is in charge of a class or activity in which the student participates 13 Any bus driver who transports the student must be able to recognize and respond to hypoglycemia and
hyperglycemia in accordance with the students Quick Reference Emergency Plan 2 TRAINED PERSONNEL 21 The following school staff members including but not limited to school administrators, teachers, counselors, health aides, cafeteria and library staff will be trained to become TDP by _________________ date: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

3 STUDENTS LEVEL OF SELF-CARE The students current ability to perform various diabetes self-management skills is indicated by activities check in the chart below: Yes No N/A Totally independent management only requires adult assistance during severe hypoglycemia Student monitors blood glucose level independently Student needs verification of blood glucose number by school nurse or TDP

_______ _______ _______

Blood glucose monitoring to be done by school nurse or TDP _______ Student administers insulin independently
Student self-administers insulin with verification of dosage by school nurse or TDP Insulin administration to be done by school nurse or TDP Student can independently program pump ie set temporary basal rates, suspend, etc
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_______ _______

_______

_______ ______

_______ _______

______

_______

Student needs assistance programming pump from school nurse or TDP

______

_______

Student can independently change infusion sets and refill and prime pump reservoir Student needs assistance with infusion set changes and pump reservoir refills and priming from school nurse or TDP Student can independently change pump batteries Students needs assistance with changing pump batteries from school nurse or TDP Student can independently trouble-shoot pump alarms and codes Student needs assistance with trouble-shooting pump from school nurse or TDP Student self-treats mild hypoglycemia Student requires assistance to treat mild hypoglycemia from school nurse or TDP Student monitors own snacks and meals Snacks and meals to be supervised by school nurse or TDP Student checks and interprets own ketones results Ketones to be checked by school
nurse or TDP Student implements universal precautions Universal precautions to be supervised by school nurse or TDP 4 SNACKS AND MEALS

______

_______

______

_______

_______ _______

_______

________

______

_______

________

_______

_______ _______

_______ _______ _______ _______ _______

41 The school nurse or TDP, if school nurse is not available, will work with the student and his/her parents/guardians to coordinate a meal and snack schedule in accordance with the attached Diabetes Medical Management Plan that will coincide with the schedule of classmates to the closest extent possible The student shall each lunch at the same time each day, or earlier if experiencing hypoglycemia The student shall have enough time to finish lunch A snack and quick-acting source of glucose must always be immediately available to the student
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42 The parents/guardians will pack snacks for each day and will provide a supply of additional snacks to be kept at the school to treat hypoglycemia or
for emergency situations 43 All school personnel will permit the student to eat a snack in the classroom or wherever the child is including, but not limited to classrooms, gym, auditorium, playground, field trips, and school bus at times designated in the Diabetes Medical Management Plan and whenever needed to treat hypoglycemia or in response to a change in the students regular schedule A source of glucose will be immediately available wherever the student is 44 The school nurse or TDP ensure that the student takes snacks and meals at the specified times each day 45 The attached Diabetes Medical Management Plan sets out the regular times for snacks each day, what constitutes a snack, when the student should have additional snacks, and where snacks are kept 5 EXERCISE AND PHYSICAL ACTIVITY 51 The student should participate fully in physical education classes and team sports 52 Physical education instructors and sports coaches must be able to recognize and assist with the treatment of hypoglycemia 53 The students blood glucose meter, a quick-acting source of glucose, and water should always be available at the site of physical education class or team sports practices and games 54
Physical education instructors and coaches will provide a safe location for the storage of the students insulin pump if the student chooses not to wear it during physical activity

WATER AND BATHROOM ACCESS 61 The student shall be permitted to have immediate access to water by keeping a water bottle in the students possession and at the students desk, and by permitting the student to use the drinking fountain without restriction 62 The student shall be permitted to use the bathroom without restriction

TREATING HIGH OR LOW BLOOD SUGAR 71 The student shall have immediate access to blood glucose monitoring equipment, insulin and syringes, insulin pump supplies, and to glucose in the form of food, juice, glucose gel or tablets in order to treat hypoglycemia The student shall be permitted to carry this equipment with him/her at all times 72 When any staff member believes the student is showing signs of high or low blood sugar, the staff member will seek the school nurse or TDP, if the school nurse is not available, for further
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assistance while making sure an adult stays with the student at all times Never send a student with actual — or suspected — high or low blood sugar
anywhere alone 73 High or low blood sugar levels should be treated as set out in the attached Diabetes Medical Management Plan 74 Any staff member who finds the student unconscious will immediately contact the school office The office will immediately do the following in the order listed: 1 Contact the school nurse or a TDP, if the school nurse is not available, who will confirm the blood glucose level with a monitor and immediately administer glucagon glucagon should be administered if no monitor is available; Call 911 office staff will do this without waiting for the school nurse or TDP to administer glucagon; and Contact the students parent/guardian and physician at the emergency numbers provided below

75 The location of supplies for treating high and low blood sugar levels, including equipment for monitoring blood glucose levels and ketones, glucagon, and snacks, is set out in the attached Diabetes Medical Management Plan 8 BLOOD GLUCOSE MONITORING 81 Blood glucose monitoring will be done in accordance with the level of self-care listed in the chart in section 3 above and the attached Diabetes Medical Management Plan 82 Blood glucose monitoring may be done at any
location at school, including, but not limited to, the classroom, on school grounds, the cafeteria, at field trips or sites of extracurricular activities, or on the school bus 83 Blood glucose monitoring will be done at the times designated in the students Diabetes Medical Management Plan, whenever the student feels that her blood sugar level may be high or low, or when symptoms of hypoglycemia or hyperglycemia are observed 84 The students usual symptoms of high and low blood sugar levels are set out in the attached Diabetes Medical Management Plan 85 The location of blood glucose monitoring equipment is set out in the attached Diabetes Medical Management Plan 86 The school or TDP, if the school nurse is not available, will perform glucose monitoring when the student is unable or chooses not to monitor himself/herself 9 INSULIN ADMINISTRATION 91 Insulin will be administered in accordance with the level of self-care listed in the chart in section 3 above and in attached Diabetes Medical Management Plan
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92 The location of insulin and equipment to administer insulin is set out in the attached Diabetes Medical Management Plan 93 If student disconnects insulin pump to engage in
physical education class or for any reason, appropriate arrangements for the safekeeping and security of the students insulin pump will be made by school personnel 10 FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES 101 The student will be permitted to participate in all field trips and extracurricular activities such as sports, clubs, and enrichment programs without restriction and with all of the accommodations and modifications, including necessary supervision by identified school personnel, set out in this Plan The students parent/guardian will not be required to accompany the student on field trips or any other school activity 102 The school nurse or TDP, if the school nurse is not available, will accompany the student on all field trips and extracurricular activities away from the school premises and will provide all usual aspects of diabetes care including, but not limited to, blood glucose monitoring, responding to hyperglycemia and hypoglycemia, providing snacks and access to water and the bathroom, and administering insulin and glucagon 103 The school nurse or TDP, if the school nurse is not available, will be available at the site of all extracurricular activities that take
place both on and away from the school premises The school nurse or TDP must be on the school premises or at the location where the activity is taking place whenever the student is participating in the activity 104 The students diabetes supplies will travel with the student to any field trip or extracurricular activity on or away from the school premises 11 TESTS AND CLASSROOM WORK 111 If the student is affected by high or low blood glucose levels at the time of regular testing, the student will be permitted to take the test at another time without penalty 112 If the student needs to take breaks to use the water fountain or bathroom, check blood glucose, or to treat hypoglycemia or hyperglycemia during a test, the student will be given extra time to finish the test without penalty 113 If the student is affected by high or low blood glucose levels or needs to take breaks to use the water fountain or bathroom, check blood glucose, or to treat hypoglycemia or hyperglycemia, the student will be permitted to have extra time to finish classroom work without penalty 114 The student shall be given instruction to help him/her make up any classroom time missed due to diabetes care without
penalty 115 The student shall not be penalized for absences required for medical appointments and/or for illness 12 DAILY INSTRUCTIONS
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121 The school nurse or TDP will notify parent/guardian ______ days in advance when there will be a change in planned activities such as exercise, playground time, field trips, parties, or lunch schedule, so that the lunch, snack plan, and insulin dosage can be adjusted accordingly 122 The parent/guardian may send the school nurse or TDP special instructions regarding the snack, snack time, or other aspects of the students diabetes care in response to changes in the usual schedule 123 Each substitute teacher and substitute school nurse will be provided with written instructions regarding the students diabetes care and a list of all school nurses and TDP at the school 13 EMERGENCY EVACUATION AND SHELTER-IN-PLACE 131 In the event of emergency evacuation or shelter-in-place situation, the students 504 Plan and Diabetes Medical Management Plan will remain in full force and effect 132 The school nurse or TDP, if the school nurse is not available, will provide diabetes care to the student as outlined by this Plan and the students Diabetes Medical
Management Plan 133 The school nurse or TDP will be responsible for transporting the students diabetes supplies, medication, and food to the evacuation or shelter-in-place designated location 134 The school nurse or TDP will remain in contact with the students parents/guardians during an evacuation or shelter-in-place situation and provide updates about the students health status and receive orders and information from parents/guardians regarding the students diabetes care 135 The students parents/guardians will be permitted to pick up the student without any unnecessary delays as soon as the student can be safely discharged

14 EQUAL TREATMENT AND ENCOURAGEMENT 141 Encouragement is essential The student must not be treated in a way that discourages the student from eating snacks on time, or from progressing in doing his/her own glucose checks and general diabetes management 142 The student shall be provided with privacy for blood glucose monitoring and insulin administration if the student desires 143 The school nurse, TDP, and other staff will keep the students diabetes confidential, except to the extent that the student decides to openly communicate about it with others

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PARENTAL NOTIFICATION 151 NOTIFY PARENTS/GUARDIANS IMMEDIATELY IN THE FOLLOWING SITUATIONS: Symptoms of severe low blood sugar such as continuous crying, extreme tiredness, or loss of consciousness
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The students blood glucose test results are below __________ or are below _________15 minutes after consuming juice or glucose tablets Symptoms of severe high blood sugar such as frequent urination, presence of ketones or blood glucose level above ______________ The student refuses to eat or take insulin injection or bolus Any injury Other: ________________________________________________________________________
___________________________________________________________________________________________ ___________________________________________________________________________________________

152 EMERGENCY CONTACT INSTRUCTIONS 1 2 3 4 Call the students home If unable to reach parent/guardian: Call the students parent/guardians cell or work phone If unable to reach parent/guardian: Repeat same steps with students other parent/guardian, if applicable If unsuccessful: Call the other emergency contacts listed above

EMERGENCY CONTACTS:

_________________________
Parents/Guardians
Name

_______________
Home Phone Number

________________
Work Phone Number

_______________
Cell Phone Number

_________________________
Parents/Guardians Name

_______________
Home Phone Number

________________
Work Phone Number

_______________
Cell Phone Number

Other emergency contacts: _________________________
Name

_______________
Home Phone Number

________________
Work Phone Number