Diabetes Care 27: 10471053 Diabetes Care 21: 14141431 Diabetes Care 26 (Suppl 1): S80S82 …
AGREEMENT FOR STUDENTS INDEPENDENTLY MANAGING THEIR DIABETES
Student School/grade
| |
|STUDENT |
| I agree to dispose of any sharps either by keeping them in my kit and |
|disposing at home, or |
|placing them in the sharps container provided at school |
| |
| I will notify the health office if my blood sugar is below ______mg/dl or |
|above _______mg/dl |
| |
| I will not allow any other person to use my diabetes supplies |
| |
| I plan to keep my diabetes supplies: ________with me ________ in the school |
|health office
|
|_____________ in an accessible and secure location located in |
|____________________ |
| |
| I understand that the freedom to manage my diabetes independently is a |
|privilege and I agree to abide by this contract |
| |
|Students Signature ___________ |
|Date ________________ |
| |
| |
|PARENT/GUARDIAN |
| |
| I agree that my child can self manage his/her diabetes and can recognize when |
|he/she needs to seek the help of a staff member |
|
|
| It has been recommended to me that back up supplies be provided to the health |
|office for emergencies |
| |
| I understand that this contract is in effect for the current school year |
|unless revoked by the physician or the student fails to meet the above safety |
|contingencies |
| |
|Parents Signature ___________ |
|Date ________________ |
| |
| |
|SCHOOL NURSE |
| |
| School staff that have the need to know about the students condition and the |
|need
to carry their diabetes supplies have been notified |
| |
|School Nurses Signature _______________ |
|Date ________________ |
