Therefore, someone with type 1 diabetes must take insulin through shots each day People with diabetes must carefully balance food, insulin intake, and activity …
Section 504 Plan
School: []
School Year: 2004-2005
[First Name] [Last Name] Insulin Dependent type 1 Diabetes
DOB: mm-yy-yyy
Grade Kindergarten
[Mom First Name] [Last Name] Mom Contact Numbers:
Moms cell: xxx-xxx-xxxx
Dads cell: xxx-xxx-xxxx
Dads Work: xxx-xxx-xxxx
Home: xxx-xxx-xxxx
[[First Name]s] Endocrinologist Numbers:
Doctors Name
Doctors Address
Office: Doctors Office Phone
Pager: Doctors Pager
The terms 504 Plan refers to a plan developed to meet the requirements
of a federal law that prohibits discrimination against people with
disabilities, Section 504 of the Rehabilitation Act of 1973 commonly
referred to as Section 504 Section 504 applies to all public schools
and to private schools that receive federal funds
BACKGROUND
The student has type 1 diabetes Diabetes is
a very serious disease for
which there is no cure The students pancreas does not produce insulin, a
hormone that is needed in order for sugar to move from the blood stream to
the cells, the process by which food provides energy for the body
Therefore, someone with type 1 diabetes must take insulin through shots
each day or by wearing an insulin pump However, insulin taken in this
manner does not cure diabetes and may cause the students blood sugar level
to become dangerously low People with diabetes must carefully balance
food, insulin intake, and activity level to try to avoid dangerously high
or dangerously low blood sugar levels
The most common immediate symptoms of high blood sugar levels
hyperglycemia are hunger, thirst, headache, blurry vision, frequent
urination, nausea, drowsiness, and the most serious possible short term
consequence diabetic ketoacidosis, which can cause breathing difficulties,
dangerous electrolyte imbalance, coma, shock, and even death The long-term
consequences of high blood sugar include eye and kidney disease, heart
attack, stroke, amputation of limbs, and a number of other serious health
problems The only way to delay the complications of diabetes
is through
tight control of the blood sugar levels
Low blood sugar levels hypoglycemia create the most common immediate
health risk for students with diabetes The most common symptoms of
hypoglycemia include tremors, palpitations and sweating, confusion,
drowsiness, mood changes, unresponsiveness, and unconsciousness
Hypoglycemia can result in seizures, brain damage, or even death
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
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 90-180 range for
optimal learning and testing of academic skills The student has a
recognized disability, type 1 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
Authorized Diabetes Care Provider ADCP: A school staff member who has
received training in the care of individuals with diabetes from a certified
diabetes nurse educator, a pediatric endocrinologist, or other diabetes
medical specialist consistent with American Diabetes Association ADA
guidelines as set out in the ADA National Standards for Diabetes Self-
Management Education and that includes 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
Diabetes Care Assistant Provider DCAP: A staff member who has received
training that is consistent with ADA guidelines and that provides
instruction in: recognizing the symptoms of hypoglycemia and hyperglycemia;
knowing the proper method for referring a student who exhibits symptoms of
hypoglycemia or hyperglycemia to an ADCP; 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
Bus Driver Diabetes Care Provider BDDCP: A bus driver who has received
training that is consistent with ADA guidelines and that provides
instruction in: recognizing the symptoms of hypoglycemia and hyperglycemia;
and knowing the appropriate steps to
take when glucose levels are creating
emergency conditions
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, which
identifies the health care, needs of - and services to be provided to - a
student with diabetes The students treating physician approves this plan
ACADEMIC-RELATED ACCOMMODATIONS
HEALTH CARE SUPERVISION
At least 4 adult staff members will receive training to be an Authorized
Diabetes Care Provider ADCP, and an ADCP 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 an ADCP is available in the
event that the primary ADCP is unavailable
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 an ADCP, 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
Any bus driver who transports the student when neither an ADCP nor DCAP is
present must be a BDDCP
TRAINED PERSONNEL
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 Authorized Diabetes Care Providers ADCPs
by [nurse], RN, CDE on [date to be trained]
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 [nurse], RN, CDE on [date to be trained]
___________________________________________________________________
The following bus drivers will be trained to become Bus Driver Diabetes
Care Providers BDDCP by [nurse], RN, CDE, on [date to be trained]
__________________________________________________________________
SNACKS AND MEALS
An ADCP will work with the student and
his/ 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 eat lunch at the same time each day, or earlier
if experiencing hypoglycemia [First Name] is in a carbohydrate count, diet
of 40g per meal 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
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
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
A designated ADCP or DCAP will ensure that the student takes his 15-20
carbohydrate counted snacks at the
specified times each day
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
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
The student shall be permitted to use the bathroom without restriction
TREATING LOW BLOOD SUGAR
The student shall have immediate access to blood glucose testing equipment,
and glucose in the form of food 15g or 4oz cup juice glucose gel or tablets
in order to treat hypoglycemia The student shall be permitted to carry
this equipment with him/ at all times
When any staff member believes the student is showing signs of high or low
blood sugar, the staff member will seek a designated ADCP 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
High or low blood sugar levels should be treated as set out in the
attached
Health Care Plan
Any staff member who finds the student unconscious will immediately contact
the school office dial 911 The office will immediately notify an ADCP
and DCAP do the following in the order listed:
1 Call 911 office staff will do this without waiting for the ADCP to
administer glucagon
2 Contact an ADCP who will confirm the blood glucose level with a
monitor and immediately administer glucagon
3 Contact [First Name]s parents and physician at the emergency
numbers, provided below
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
GLUCOSE TESTS
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
Glucose tests may be done at any location at school, including, but not
limited to, the classroom, on school grounds, at field trips or sites of
extracurricular activities, or on the school bus
Glucose tests will be done at the times designated in the students
Health
Plan, whenever the student feels that his blood sugar level may be high or
low, or when an ACDP or DCAP observes symptoms of hypoglycemia or
hyperglycemia
The students usual symptoms of high and low blood sugar levels are set out
in the attached Health Care Plan
The location of glucose testing equipment is set out in the attached Health
Care Plan
An ADCP will perform glucose tests when the student is unable or chooses
not to do the test him/self
INSULIN INJECTIONS
Insulin will be administered in accordance with the level of self-care
listed in the attached Health Plan
The location of insulin and equipment to administer insulin is set out in
the attached Health Care Plan
FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES
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 but will need to be
notified
An ADCP
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
Either a DCAP or an ADCP will be available at the site of all
extracurricular activities that take place on school premises An ADCP must
be on the school premises whenever the student is present
The students diabetes supplies will travel with the student to any field
trip or extracurricular activity on or off of school premises
TESTS AND CLASSROOM WORK
1 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
2 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
3 The student will be permitted to have
extra time to finish classroom
work 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 without
penalty
4 The student shall be given instruction to help him/her make up any
classroom time missed due to diabetes care without penalty
5 The student shall not be penalized for absences, and delays required
for medical appointments and/or for illness
DAILY INSTRUCTIONS
1 An ADCP or DCAP will notify parent/guardian 3 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 or snack plan can be adjusted accordingly
2 The parent/guardian may send the ADCP special instructions regarding
the snack, snack time, or other aspects of the students diabetes care
in response to changes in the usual schedule
3 An ADCP must provide any substitute teacher with written instructions
regarding the students diabetes care and a list of all ADCPs and
DCAPs at the
school
EQUAL TREATMENT AND ENCOURAGEMENT
1 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 blood glucose tests and general
diabetes management
2 The student shall be provided with privacy for blood glucose testing
and insulin administration if the student desires
ADCPs, 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
PARENTAL NOTIFICATION
NOTIFY PARENTS/GUARDIANS IMMEDIATELY IN THE FOLLOWING SITUATIONS:
Symptoms of severe low blood sugar such as continuous crying, extreme
tiredness, sweaty palms, pale skin, irritable or loss of consciousness
The students blood glucose test results are below 70 or are below 80, 15
minutes after consuming juice or glucose tablets
Symptoms of severe high blood sugar such as frequent urination, extreme
thirst, hunger, blurred vision, drowsiness, or presence of -large ketones
or blood glucose level above 300
The student refuses to eat or take insulin injection
Any injury
Other: Any
reason you feel you need to contact Mom Cell: [xxx-xxx-xxxx]
EMERGENCY CONTACT INSTRUCTIONS
1 Call the students mother at work If unable to reach parent/guardian:
2 Call the students parent/guardians cell or work phone If unable to
reach parent/guardian:
3 Call [Moms First Name]Mom at [xxx-xxx-xxxx]
If unsuccessful:
4 Call [Mom] at [Home][ xxx-xxx-xxxx]
EMERGENCY CONTACTS:
[Fathers First Name] Father
Cell: [xxx-xxx-xxxx]
Work: [xxx-xxx-xxxx]
Home: [xxx-xxx-xxxx]
Other emergency contacts:
[Emergency Contact] Relation]
Home: [xxx-xxx-xxxx]
Cell: [xxx-xxx-xxxx]
Students Physicians:
Doctors Name
Doctors Address
Doctors Phone Number
This Plan shall be reviewed and amended at the beginning of each school
year or more often if necessary
Reviewed:
_______________________________________________
Physician Signature Date
_______________________________________________
Parent/Guardian Date
_______________________________________________
School Representative and Title Date
