Type 1 diabetes is a very serious disease for which there is no cure. People with diabetes must carefully balance food, insulin intake, and activity …
Requirements for [Name], prepared in accordance with Section 504 of the
Rehabilitation Act of 1973, the Individuals with Disabilities Education
Act, and the Americans with Disabilities Act
1 Describe the basis for the determination of disability if any:
Type 1 diabetes, as diagnosed by a physician, is a physiological disorder
that affects the endocrine system [Firstname] has been diagnosed by, and
is currently under the care, of [Doctor] of [Hospital/Medical Center]
2 Describe how the disability affects a major life activity:
Type 1 diabetes is a very serious disease for which there is no cure The
students pancreas does not produce insulin, a hormone which 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 or high
People with diabetes must carefully balance food, insulin intake, and
activity level to try to avoid dangerously high or
dangerously low blood
sugar levels Type 1 diabetes thus places the individual at risk for
hypoglycemic and hyperglycemic episodes related to metabolic dysfunction,
and these potential fluctuations in blood glucose impact the individuals
major life activities in the area of learning
3 Goals and objectives of the program:
Both high blood sugar levels and low blood sugar levels affect
[Firstname]s ability to learn and perform, as well as seriously
endangering her health Blood glucose levels must be maintained in the 80-
180 range for optimal learning and testing of academic skills [Firstname]
has a recognized disability, type 1 diabetes, that requires the
accommodations and modifications set out in this plan to ensure that she
has the same opportunities and conditions for learning and academic testing
as classmates, with minimal disruption of her 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 any necessary medical information
These documents and appropriate procedures have been discussed and agreed
upon in a conference
between [Firstname]s parents and the school nurse
and/or administration
4 Describe the accommodations that are necessary:
A [Firstname] shall be permitted to use the bathroom without
restriction
B [Firstname] shall be permitted to have immediate access to water,
including keeping a water bottle in her possession and being allowed to use
the drinking fountain without restriction
C [Firstname] shall be permitted to have snacks whenever necessary
during the school day
D [Firstname] shall be permitted to leave class to see the nurse for
diabetes related issues
E [Firstname] shall have immediate access to all items necessary for
the treatment of diabetes, including but not limited to blood glucose
testing equipment, insulin, and glucagon, and shall be permitted to carry
these items with her at all times
F Blood glucose tests may be done at any location in 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
G [Firstname] 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
set out in this plan
H If [Firstname] is affected by high or low blood glucose levels at the
time of regular or standardized testing, she will be permitted to take the
test at another time without penalty
I If [Firstname] 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 or a classroom assignment, she will be given
extra time to finish the test or assignment without penalty
J [Firstname] will not be penalized for absences or tardiness required
for medical appointments, illness, visits to the nurses office, or time
necessary to maintain blood glucose control
K [Firstname]s parents will be notified no later than August 1st as to
who [Firstname]s homeroom teacher will be [Firstname]s parents and/or
[Firstname]s physician will provide the teacher with information regarding
the rights and needs of children with diabetes while in a school/classroom
setting
L A conference will be scheduled with [Firstname]s homeroom teacher,
nurse, the parents, and any other parties relevant to [Firstname]s
diabetes care no later than
one day prior to the first day of school
M The parents and [Firstname] will be allowed to discuss diabetes with
[Firstname]s homeroom classmates during the first week of school
N The parents will be notified in the event that school is to be
dismissed early inclement weather, etc and [Firstname] will not be put
on the bus until the parents are notified Phone messages are not to be
considered notified
O [Firstname] will be allowed to wear her medical alert bracelet while
at school She will not be asked to remove it under any circumstances
P If [Firstname]s parents feel it is necessary, they will accompany
[Firstname] on field trips, regardless of the limited amount of parents
permitted to attend the field trip Should an emergency arise and it is not
possible for either parent to attend the field trip, the school will
provide a qualified nurse or another adult approved by the parents to
accompany [Firstname] on the field trip [Firstname] will be able to take a
sack lunch on field trips even if a designated lunch is provided at the
sight of the field trip
Q [Firstname] will be allowed to have enough time to finish her lunch
and snacks, and her snack consumption shall be
monitored by an adult to
ensure that she finishes the necessary amount
R The school will provide [Firstname] parents with the carbohydrate
counts on all food items that are served in the school cafeteria This
information will be provided no later than one day prior to the school year
beginning
S If [Firstname] shows signs of hypoglycemia or hyperglycemia she will
immediately be given the appropriate treatment, and will be not be left
unaccompanied by an adult until the treatment has begun The parents will
provide instructions regarding the type of treatment to be administered
All teachers, teaching assistants, special area teachers, recess duty
supervisors, and anyone else who may be supervising [Firstname] will be
trained by the school and the parents on the signs of hypo/hyperglycemia
and the proper treatments A detailed medical plan will be provided by the
parents, describing in detail all health matters related to [Firstname]s
condition, which the school will keep distribute to all relevant faculty
and staff, and shall keep readily available
T The school will ensure that there will be at least one adult staff
member with training as an Authorized Diabetes Care Provider
ADCP, and
this ADCP will be available at all times during school hours, during
extracurricular activities, and on field trips to oversee the students
health care, including performing or overseeing insulin injections, blood
glucose tests, ketone tests, and responding to hyperglycemia and
hypoglycemia including administering glucagon An Authorized Diabetes Care
Provider ADCP is defined as: 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
U If necessary, especially in cases of high blood sugar, insulin will
be administered by a qualified adult as needed and as directed by
physician Insulin amounts, procedures, and doctors phone numbers shall be
provided by the parents
V Ketones will be checked when blood sugar is over 250, or when
[Firstname] complains of stomach pains The parents will immediately be
notified if any ketones are found in her urine, and the school will take
such actions as
prescribed by the parents in [Firstname]s medical plan If
the parents are not available, and the ketones are moderate or higher,
[Firstname]s doctor is to be contacted immediately
W [Firstname] will not participate in gym class if her blood sugar is
over 300 and/or ketones small or larger are present Non-participation in
gym due to this reason will not affect her grade for gym class
X The school will provide the parents with daily reports as to
[Firstname]s blood sugar levels and any and all treatments provided during
the school day
Y In the event of seizure or unconsciousness, an injection of Glucagon
will be given by the nearest trained adult immediately, in accordance with
written instructions provided by the parents The school will also call
911, the parents, and [Firstname]s doctors immediately, in that order
Z If [Firstname]s parents cannot be contacted regarding any aspect of
her medical treatment, school personnel will contact her physician Phone
numbers will be provided by the parents
AA [Firstname] shall never be sent anywhere alone, under any
circumstances
