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HomeSchool Nurse's Forms

The Virginia DiabetesCouncil ( VDC) is working to increase access to evidenced-based resources andpromote self-awareness and self-management of diabetes. The VDC encourageshealth care providers and people with diabetes to use the following highquality resources for diabetes management and control.

     Here is the latest NDEP information for school personnel workingwith students with diabetes.
     http://ndep.nih.gov/media/Youth_NDEPSchoolGuide.pdf

 

School Resources,Forms and Protocol 2013-14


TheVirginia Diabetes Medical Management Plan and Protocol: A Supplement to theNational Diabetes Education Program’s Helping the Student with DiabetesSucceed: A Guide for School Personnel is to be used as a quick reference guideto promote and ensure excellence, safety and support for children with diabetesin Virginia’s schools.


Virginia Diabetes Medical Management Plan and Protocol Supplement-School Forms

The Virginia DiabetesCouncil and the Department of Education, Office of Student Services supportsthe use of the these school forms as a way to provide quality and standardizedcare for children with diabetes in all school systems in Virginia. 


Part 1 - School nursedistributes this form to the parent/guardian to determine permission or denialof permission for insulin and/or glucagon administration by trained unlicensedpersonnel.

Part 2 - Physician distributes these forms to parents to sign and bringto their child’s school to authorize communication between the school andphysician on diabetes care.

 

Part 3 - If the child wearsan insulin pump, then this form needs to be completed by the physician and theparent/guardian to provide child’s proficiency of pump operation and where theywill require assistance/supervision.

Part 4 – If the child is goingto carry or self administer insulin and/or perform blood glucose checks in theclassroom, this form is recommended to be completed by the physician, schoolnurse and parent/guardian to inform everyone of expectations andresponsibilities.

Other Recommended School Resources: