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Diabetes school plan

  • 2022 Diabetes school plan

    All school plan requests will be completed in order of the date received.

    Expect to receive your plan within three weeks after you submit this form via email. In the meantime your 2021 plan can be used by your child's school.

    If a box is left blank we will fill it in as per RCH guidelines.

    Details

    First name 

    Last name

    Date of birth

    Grade at school (2022)

    Name of school

    Hospital UR number

    Guardian name

    Guardian email address (to email plan to) 

    Guardian contact number

    Who is your Diabetes Nurse Educator?

    How many times per day does your child have insulin?

    What is your child currently taking?

    Does your child require an insulin injection at school?

    Names of responsible staff who have voluntarily agreed to undertake training and provide support with diabetes care to the student

    If your child has an insulin injection at school

    Is supervision required? All primary school aged children must be supervised giving injections. 

    If your child requires supervision or assistance with administering insulin at school please contact your diabetes nurse educator at the start of returning to school to request a Medication Authority Form 

    Type of injection device

    Location in the school where the injection will be given

    Blood glucose checking

    Does your child require a BGL test at recess/snack?

    Does your child do their own BGL testing?

    Do they require

    Hypo management 

    Hypo management box location?

    What type of fast acting hypo food does your child have at school?

    Explain what type of hypo treatment your child uses when at school 

    What type of long acting hypo food does your child have at school?

    Explain how much long acting carbohydrate your child needs at school

    Activity food box location

    What carbohydrates does your child use before sport and activity at school?

    Explain what activity food your child needs and how much for sport/exercise at school 

    Diagnosis of Coeliac disease

    Does child keep any extra diabetes supplies at school?

    Is your child on an insulin pump?

    Which model of pump does your child use?

    Student pump skills

    Able to independently count carbohydrates?

    Able to enter a BGL and carbohydrate grams into the pump?

    Able to do a correction bolus?

    Able to disconnect and reconnect pump if needed?

    Restart pump manually?

    Able to prepare and insert a new infusion set if needed?

    Give an insulin injection if needed?

    Able to troubleshoot pump alarms and malfunctions?

    In your child currently using CGM?

    Which CGM does your child use?

    With an insulin pump and using CGM does your child use?

    Please add any additional comments