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School Nurse Forms for Students with Diabetes


The Virginia Diabetes Council and the Department of Education: Office of Student Services supports the use of the these school forms as a way to provide quality and standardized care for children with diabetes in all school systems in Virginia.

Virginia School Diabetes Medical Management Forms (DMMP)

Updated June 2016 Download DMMP Form


This process of using this form and creating proper protocol for students with diabetes involves 4 parts.


Part 1- School nurse distributes this form to the parent/guardian to determine permission or denial of permission for insulin and/or glucagon administration by trained unlicensed personnel.

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

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

Part 4– If the child is going to carry or self administer insulin and/or perform blood glucose checks in the classroom, this form is recommended to be completed by the physician, school nurse and parent/guardian to inform everyone of expectations and responsibilities.



504 Plan:

Many children with diabetes have a 504 plan in order to outline the best methods for diabetes management while in school. This plan, refers to a plan developed to meet the requirements of a federal law that prohibits discrimination against people with disabilities. (under Section 504 of the Rehabilitation Act of 1973.) A 504 Plan sets out the actions the school will take to make sure the student with diabetes is medically safe, has the same access to education as other children, and is treated fairly. If you know a child with diabetes that is newly diagnosed or does not have a 504 plan, use the links below to start the process of implementing a plan at their school. You may also contact the school's 504 Coordinator for more information.

Other Recommended Resources: