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Home My WebLink AboutOCDSB 963 Plan of Care Diabetes 2020OCDSB 963 (Diabetes) 1 OCDSB 963: PLAN OF CARE FOR STUDENTS WITH DIABETES (References: P.108.SCO, PR.548.SCO, PR.547.SCO, and PR.632.SCO) The information on this form is collected annually and deemed valid until August 31 of each school year. Student Information (Attach a recent photo of student) •Student Name (first, middle, last): _____________________________________________ •Student Date of Birth: ______________________ •School Name: ______________________________________________________ •Grade: ______________________ •Student Number: ______________________ •Teacher Name: ________________________________________ Parent/Guardian Information (required if student is under 18 years of age) •Parent/Guardian First and Last Name : ______________________________________ •Home Phone number: _________________________________ •Parent Email Address: ________________________________________ Emergency Contacts (Please list in order of priority) Name Relationship Daytime Phone Alternate Phone Email 1. 2. 3. OCDSB 963 (Diabetes) 2 •Profession/Role: ________________________________________ Diabetes Specialist Information Same as Primary Healthcare Provider. Different from Primary Healthcare Provider (Complete the following information) ■Name: __________________________________________________ ■Telephone Number: _______________________________________ ■Profession/Role: Physician Nurse Practitioner Registered Nurse Pharmacist Respiratory Therapist Certified Respiratory Educator Certified Asthma Educator Other Please specify: ________________________________________________ Primary Healthcare Provider Information •Name: __________________________________________________ •Telephone Number: ______________________________ I/We authorize the school staff to contact the above health care provider as required to attend to the well-being of the student. Please attach the most recent, original instructions, prescriptions, and labels pertaining to each medication. Date of prescription/notes must be captured. OCDSB 963 (Diabetes) 3 Student has continuous glucose monitor (CGM) Please check appropriate routine BG checking times Balanced Day Before 1st Nutrition Break Before 2nd Nutrition Break Regular Day Before Morning Break Before Lunch Before Afternoon Break Before getting on bus Before Activity/PE class Field trips When showing signs of low blood glucose When showing signs of high blood glucose Other: _______________________________________________________________ Daily Management Procedures BLOOD GLUCOSE (BG) MONITORING Student requires trained staff to check BG/read meter Student needs supervision to check BG/read meter Student can independently check BG/read meter OCDSB 963 (Diabetes) 4 ●Recommended time(s) for meals/snacks: ______________________________________ ●Special instructions for special events: ______________________________________ INSULIN Student does not take insulin at school. Please proceed with the ACTIVITY PLAN section. Student takes insulin at school. Please complete the following questions. Insulin is given by: Student Student with supervision Parent/Guardian Other: _______________________________________________________ Optimal BG Range: ____________________________________________________ Contact Parent/guardian if BG is: ______________________________________ Method of Communication Phone Call Email Other. Please specify: _____________________________________________ NUTRITION BREAKS Student requires supervision during meal times to ensure completion. Student can independently manage their food intake. OCDSB 963 (Diabetes) 5 Yes No ●Blood glucose must be checked before the child eats and will (check one) Be sent to the pump by the meter Be entered into the pump ACTIVITY PLAN Please indicate what the student must do to help prevent a low BG (i.e. take food or test) ●Before exercise: ______________________________________________________ ●During exercise: ______________________________________________________ ●After exercise: _______________________________________________________ Insulin required at the following times: Balanced Day -Before 1st Nutrition Break Balanced Day - Before 2nd Nutrition Break Regular Day - Before Morning Break Regular Day - Before Lunch Regular Day - Before Afternoon Break Other: ____________________________________________________ Student takes insulin at school by: Injection. OCDSB staff does not provide insulin injections. Pump. Please answer the following questions: ●Always use the insulin pump bolus calculator: OCDSB 963 (Diabetes) 6 Disposal Instructions: ________________________________________________________ I/We acknowledge that it is my/our responsibility to submit enough backup medication and medical supplies to school and to track the expiration date. OTHER REQUIRED ACCOMMODATION Emergency Management Procedures MANAGING LOW BLOOD GLUCOSE (HYPOGLYCEMIA) _____ mmol/L or less Usual symptoms of low blood glucose for this student are: Shaky Irritable/grouchy Dizzy Do you authorize the student to carry their Diabetes Management Kit at all times? Yes. Location of Kit on student: ____________________________________________ No. Location of Kit elsewhere: _____________________________________________ Please specify location of backup Kit in school: ______________________________________ Storage Cautions (if any): ________________________________________________________ DIABETES MANAGEMENT KIT The kit will include (check all that apply): Fast-acting sugar, carbohydrate snack in emergency Gel or Icing sugar for Severe low BG Blood glucose meter and test strips, lancets. Insulin pen, pen needles or syringe, insulin (in case of pump failure). Contact numbers OCDSB 963 (Diabetes) 7 Specific Course of Action for Hypoglycemia: Specific Course of Action for Severe Hypoglycemia (student is unconscious/ unresponsive): ____________________________________________________ mmol/L or higherMANAGING HIGH BLOOD GLUCOSE (HYPERGLYCEMIA) __________ Usual symptoms of high blood glucose for this student are: Extreme thirst Excessive voiding Headache Hungry Abdominal pain Blurred vision Warm, flushed skin Irritability Other ________________________________________________ Sweating Headache Blurred vision Hungry Weak/fatigue Fast heartbeat Pale Anxious Other: ___________________________________________________ OCDSB 963 (Diabetes) 8 In life-threatening emergencies, staff will administer prescribed medication to students “in loco parentis”, not as healthcare professionals. I/We authorize the OCDSB staff to administer prescribed medication to the student as prescribed. I/We understand that OCDSB staff is not medically trained to administer medication and bear sole responsibility for any adverse reaction that might occur following the administration of medication. The student is capable of administering their own medication. I/We bear sole responsibility for any adverse reaction that might occur following the self-administration of medication. Consent to Release Information Does the student use OSTA bus on a regular basis? Yes. A copy of the Student Care Plan will be shared with OSTA. No. Specific Course of Action: _______________________________________________ Parent(s)/Guardian(s) Authorization to Administer Medication The administration of medication involves certain elements of risk, including, but not limited to illness, adverse reactions or other complications. Reactions caused by the administration of any medication can occur without fault on any party; the student, or the OCDSB or its employees or agents. By requesting and consenting to the administration of medication by an employee of the OCDSB, or by authorizing the self-administration of medication by the student, you are assuming any associated risks. Rapid, shallow breathing Vomiting Fruity breath Specific Course of Action: ___________________________________________________________ Symptoms of Severe/dangerous high blood glucose for this child are: The personal information of this form is collected under the authority of the Education Act (RSO. 1990 c.E.2) and in accordance with the Municipal Freedom of Information and Protection of Privacy Act (RSO. 1990 c.M56), as amended. It will be used to establish the Ontario Student Record [OSR] and for student and education related purposes such as registration, administration, communication, collection of fees, data reporting, and Student Transportation Services. In addition, the information may be used or disclosed to comply with legislation, for compelling circumstances affecting health and safety or discipline, as required in circumstances related to allow enforcement matters, and with third parties in accordance with established service agreements or in accordance with any other Act. Questions or concerns should be directed to the school principal or the Board’s Freedom of Information Coordinator, Ottawa-Carleton District School Board, 133 Greenbank Road, Ottawa, Ontario, K2H 6L3, Telephone 613-596-8211 ext. 8607. OCDSB 963 (Diabetes) 9 Parent(s)/guardian(s)/Adult Student Name: _____________________________________ Parent(s)/guardian(s)/Adult Student signature: ____________________________________ Date: __________________ I/We give consent for the school to share this Plan of Care as necessary with individuals in direct contact with the student to attend to their well-being and medical needs at school and during school activities. This may include school and office staff, occasional staff, OSTA, contracted bus operators and bus drivers, before- and after-school program staff. This plan will be posted in identified areas of the school for emergency response purposes. I confirm that the information herein is accurate and up to date. I understand that I must re-submit this form in case of any changes to the student’s medication, condition, level of independence, or treatment plan. /!-- This code was added to remove the metadata from document view in Weblink -->