People with type 1 diabetes do not this manner does not cure diabetes and may cause the student’s blood glucose level to become diabetes. …

DREDF
Disability Rights Education and Defense Fund, Inc

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

Section 504 Plan for ___________________
School ________________________ School Year: _________________

______________________________
Students Name

________________
Birth Date

_____
Grade

_____________
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 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 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 immediate health problem for students with diabetes It occurs when the body gets too much insulin, too little food, a delayed meal, 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, too much food or too little exercise; it may also be caused by stress or an illness such as a cold The most common symptoms of hyperglycemia are thirst, frequent urination, and blurry vision If untreated over a period of days,
1

hyperglycemia can cause 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, and the accompanying Health Plan, 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

OBJECTIVE/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 Health Care Plan, which is attached to this Section 504 Plan and incorporated into it

DEFINITIONS USED IN THIS PLAN
1 Diabetes Care Provider DCP: A staff member who has received training in the care of individuals with diabetes from a health care professional with expertise in diabetes, unless the students health care provider determines that the parent/guardian is able to provide the school personnel with sufficient oral and written information to allow the school to have a safe and appropriate environment for the child, in which case the parent/guardian may provide this training This training shall include instruction in: the unassisted administration of glucagon and insulin shots and recording of results; understanding physician instructions concerning drug dosage, frequency, and manner of administration; applicable state regulations concerning drug storage, security, and record-keeping; symptoms of hypoglycemia and hyperglycemia and the time within which glucagon or insulin shots are to be administered to prevent adverse consequences; recommended schedules and menus for
meals and snacks, recommended frequency of and activities in exercise periods, and actions to take if normal schedule is disrupted

performing finger-stick blood glucose testing, urine ketone testing, and recording the results; and the appropriate steps to take when glucose level results are outside of the target ranges indicated in the students Health Care Plan

2 Diabetes Care Assistant Provider DCAP: A staff member who has received training from a health care professional with expertise in diabetes, a DCP, or the students parent/guardian if the students health care provider determines that the parent/guardian is able to provide the school personnel with sufficient oral and written information to allow the school to have a safe and appropriate environment for the child This training shall include instruction in: recognizing the symptoms of hypoglycemia and hyperglycemia; knowing the proper method for referring a student who exhibits symptoms of hypoglycemia or hyperglycmeia to a DCP; and recommended schedules and menus for meals and snacks, recommended frequency of and activities in exercise periods, and actions to take if normal schedule is disrupted

3 Bus Driver
Diabetes Care Provider BDDCP: A bus driver who has received training by a health care professional with expertise in diabetes, a DCP, or the students parent/guardian if the students health care provider determines that the parent/guardian is able to provide the school personnel with sufficient oral and written information to allow the school to have a safe and appropriate environment for the child This training shall include instruction in: recognizing the symptoms of hypoglycemia and hyperglycemia; and knowing the appropriate steps to take when glucose levels are creating emergency conditions

4 Health Care Plan: A plan developed under Section 504 of the Rehabilitation Act of 1973, the Americans With Disabilities Act of 1990, and, as appropriate, the Individuals With Disabilities Education Act, that identifies the health care needs of — and services to be provided to — a student with diabetes This plan is approved by the students treating physician

ACADEMIC-RELATED ACCOMMODATIONS
1 HEALTH CARE SUPERVISION 11 At least _______ adult staff members will receive training to be an Diabetes Care Provider DCP, and a DCP will be available at all times during school hours, during
extracurricular activities, and on field trips to oversee the students health care in accordance with this Section 504 Plan and the students Health Care Plan, including performing or overseeing insulin injections, blood glucose tests, ketone tests, and responding to hyperglycemia and hypoglycemia including administering glucagon A written back-up plan will be implemented to ensure that a DCP is available in the event that the primary DCP 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 DCP, shall receive training to be a DCAP 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 when neither a DCP nor DCAP is present must be a BDDCP 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 Diabetes Care Providers DCPs by _________________ date:
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

22 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 Diabetes Care Assistant Providers DCAPs by __________________________ date: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 23 The following bus drivers will be trained to become Bus Driver Diabetes Care Providers BDDCP by __________________________ date: _____________________________________________________________________________ _____________________________________________________________________________
_____________________________________________________________________________

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 tests blood glucose level independently Student needs verification of blood glucose number by circle one or both DCP DCAP Blood glucose testing to be done by DCP Student administers insulin independently Student self-injects insulin with verification of dosage by circle one or both DCP DCAP Insulin injections to be done by DCP Student self-treats mild hypoglycemia Student requires assistance to treat mild hypoglycemia from: circle one or both DCP DCAP Student monitors own snacks and meals Snacks and meals to be supervised by: circle one or both DCP DCAP

_______ _______ _______

_______ _______

_______ _______ _______

_______ _______

_______
_______

_______

Student tests and interprets own urine ketones Urine ketones to be tested by DCP Student implements universal precautions Universal precautions to be supervised by: circle one or both DCP DCAP

_______ _______ _______ _______

SNACKS AND MEALS 41 A DCP will work with the student and his/her parents/guardians to coordinate a meal and snack schedule in accordance with the attached Health Care 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 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 Health Care 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 A designated DCP or DCAP will ensure that the student takes snacks and meals at the specified times each day 45 The attached Health Care 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

WATER AND BATHROOM ACCESS 51 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 52 The student shall be permitted to use the bathroom without restriction

6 TREATING HIGH OR LOW BLOOD SUGAR 61 The student shall have immediate access to blood glucose testing equipment, insulin and syringes, 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 62 When any staff member
believes the student is showing signs of high or low blood sugar, the staff member will seek a designated DCP for further 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 63 High or low blood sugar levels should be treated as set out in the attached Health Care Plan

64 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 a DCP 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 DCP to administer glucagon; and Contact the students parent/guardian and physician at the emergency numbers provided below

65 The location of supplies for treating high and low blood sugar levels, including equipment for testing blood glucose levels and ketones, glucagon, and snacks, is set out in the attached Health Care Plan 7 GLUCOSE TESTS 71 Blood glucose tests will be administered in accordance with the
level of self-care listed in the chart in section 3 above and the attached Health Care Plan 72 Glucose tests 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 73 Glucose tests will be done at the times designated in the students Health Plan, whenever the student feels that her blood sugar level may be high or low, or when an ACDP or DCAP observes symptoms of hypoglycemia or hyperglycemia 74 The students usual symptoms of high and low blood sugar levels are set out in the attached Health Care Plan 75 The location of glucose testing equipment is set out in the attached Health Care Plan 76 A DCP will perform glucose tests when the student is unable or chooses not to do the test himself/herself 8 INSULIN INJECTIONS 81 Insulin will be administered in accordance with the level of self-care listed in the chart in section 3 above and in attached Health Plan 82 The location of insulin and equipment to administer insulin is set out in the attached Health Care Plan

9 FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES 91 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 92 A DCP will accompany the student on all field trips and extracurricular activities outside of the schools premises and will provide all usual aspects of diabetes care including, but not limited to, blood glucose testing, responding to hyperglycemia and hypoglycemia, providing snacks and access to water and the bathroom, and administering insulin and glucagon 93 Either a DCAP or a DCP will be available at the site of all extracurricular activities that take place on school premises A DCP must be on the school premises whenever the student is present 94 The students diabetes supplies will travel with the student to any field trip or extracurricular activity on or off of school premises 10 TESTS AND CLASSROOM WORK 101 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 102 If the student needs to take breaks to use the water fountain or bathroom, do a blood glucose test, or to treat hypoglycemia or hyperglycemia during a test, the student will be given extra time to finish the test without penalty 103 If the student is affected by high or low blood glucose levels or needs to take breaks to use the water fountain or bathroom, do a blood glucose test, or to treat hypoglycemia or hyperglycemia, the student will be permitted to have extra time to finish classroom work without penalty 104 The student shall be given instruction to help him/her make up any classroom time missed due to diabetes care without penalty 105 The student shall not be penalized for absences required for medical appointments and/or for illness 11 DAILY INSTRUCTIONS 111 A DCP or DCAP will notify parent/guardian ______ days in advance when there will be a change in planned activities such as exercise, playground time, fieldtrips, parties, or lunch schedule, so that the lunch, snack plan, and insulin dosage can be adjusted accordingly 112 The parent/guardian may send the DCP special instructions
regarding the snack, snack time, or other aspects of the students diabetes care in response to changes in the usual schedule 113 A DCP must provide any substitute teacher with written instructions regarding the students diabetes care and a list of all DCPs and DCAPs at the school
8

12 EQUAL TREATMENT AND ENCOURAGEMENT 121 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 tests and general diabetes management 122 The student shall be provided with privacy for blood glucose testing and insulin administration if the student desires 123 DCPs, DCAPs, BDDCPs, and other staff will keep the students diabetes confidential, except to the extent that the student decides to openly communicate about it with others

13 PARENTAL NOTIFICATION 131 NOTIFY PARENTS/GUARDIANS IMMEDIATELY IN THE FOLLOWING SITUATIONS: Symptoms of severe low blood sugar such as continuous crying, extreme tiredness, or loss of consciousness 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 Any injury Other: ________________________________________________________________________
___________________________________________________________________________________________ ___________________________________________________________________________________________

132 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

_______________
Cell Phone Number