ࡱ> y{x +bjbj "jjj '+lvvvv   8P \ ,3^ 4 #AT,]]]]]]]$_ an]"#]vv 9]4v8  ]]Z ] ߋ>  |]<]$^03^R]<kbqvkb]vvvv504 Plan for the School Year 2002/2003 Student Name: [name] Date of Birth: [birthday] School: [school] Grade: 4 Teacher: [teacher] Parent: [parent name] Phone: [phone] Address: [address] Date of Disability Determination: [date diagnosed]  [Name] has type 1 diabetes mellitus. This is a condition in which the pancreas is unable to make insulin. Without insulin, the body cannot change glucose (sugar) into the energy a person needs. To compensate for the lack of natural insulin, he wears an insulin pump. With the help of a qualified adult, [Name] uses his insulin pump to administer the correct doses of insulin to match the carbohydrates in the food he eats (bolus) and the amount his body needs without food (basal rates). [Name]s basal rates and boluses must be balanced with his meals, snacks and regular physical activity. To consistently achieve this balance, he must check his blood sugar frequently. Depending on the daily classroom schedule, [Name] will need to check his blood glucose level before snack, lunch, recess, and before and after physical education class, as well as when his body tells his blood glucose is low or too high. We will review his schedule for checking blood sugar prior to the start of each school year and attach a current schedule to this 504 prior to the start of each school year. Blood glucose levels must be maintained in the 80-180 range for optimal learning and testing of academic skills. [Name]s behavior is related to blood glucose levels. He can feel tired, sluggish and hungry when his blood glucose is high and empty or spacey when it is low. When [Name] is excited and/or stressed, as in a testing situation, his blood glucose can potentially go up. When his blood glucose is high (over 180) his body responds by trying to decrease this glucose level. He may become thirstier as his body is acting to dilute or flush out the extra sugar. He needs to drink more water and then urinate more frequently. Information/Communication All teachers will be notified each year that [Name] has diabetes and will be instructed on what to do in the event of a hypoglycemic reaction. At least one adult who is qualified to administer all diabetes related care will be available at all times. i.e., nurse or nurses designee. All teachers will receive a folder containing information regarding [Name]s care, management and emergency procedures. If a concern arises regarding [Name]s health or academic progress as affected by diabetes, there will be no hesitation to arrange a meeting among appropriate school personnel and parents. Substitute teachers will be given information regarding [Name]s diabetic care. [Name]s parents will continue to send in all supplies for insulin pump, blood glucose monitoring, and keytone monitoring. They will provide juice boxes and complex carbohydrate snacks for treating hypoglycemia. [Name]s parent will be notified as soon as possible if the school nurse will not be in the school and a member of the office staff will be trained to care for [Name] in her absence. The nurse will notify [Name]s parent when supplies are getting low. Water and bathroom access [Name] shall be permitted to have access to water at all times, including keeping a water bottle in his possession and access to drinking fountain without restriction. [Name] shall be permitted to use the bathroom without restriction. [Name]s teacher will notify his parents if drinking or bathroom frequency seems excessive. Snacks and Meals [Name]s parent will provide a chart listing the appropriate bolus amounts for correcting high blood sugar and the amount of bolus required for various carbohydrate counts in his meal or snack. [Name]s parent will also provide a chart for daily communication with the school nurse. The chart will include the carbohydrate amounts in [Name]s snack/lunch so the school nurse can calculate the appropriate bolus. The nurse will document blood sugar values and boluses given on a daily basis in the chart. [Name]s parent will provide juice boxes and glucose tabs to be kept in the classroom and in the nurses office to treat hypoglycemia. All school personnel will permit [Name] to eat a snack in the classroom or wherever he is (including, but not limited to classrooms, gym, auditorium, school grounds, field trips, and school bus) whenever needed to treat hypoglycemia. School Nutritional staff will supply nutritional information (ie. Carb counts) on all lunch menu items. The teacher or nurse will contact the parent before giving any extra snacks that might have been brought in by other students, such as with birthdays or holiday parties. Low Blood Sugar If [Name] has a hypoglycemic reaction, he is to test his blood sugar and treat with a juice box and/or glucose tabs in class. If low blood sugar <70 is confirmed, [Name] must not be left alone until he over 80. If [Name] has treated a low, he should test again in 15 minutes to confirm he is coming back into normal blood sugar range. Additional IMPORTANT information on treating a low can be found in the attached physician protocol, including use of the glucagon in the event of loss of consciousness or seizure. [Name] will use the buddy system when out of the classroom and MUST be accompanied by another student or teacher to the nurses office. He must NEVER be allowed to go to the nurses office alone if a low blood sugar is suspected. If the nurse is not in the building, the principal, assistant principal, or designated office personnel will have [Name] check his blood sugar, treat him per protocol, and then notify his parents. High Blood Sugar High blood sugar will be monitored closely and treated per attached physician protocol. Lack of insulin supply, which can occur with a pump malfunction or an occlusion in the tubing or infusion site, may lead to diabetic ketoacidosis (DKA) in several hours. Glucose Checks The goal is to minimize disruptions in [Name]s regular school schedule and minimize time away from the classroom. A meter will be kept in the nurses office and a vial of insulin will be kept in the nurses office refrigerator. Glucose checks will be administered any time [Name] feels his blood sugar may be high or low, and any time an adult suspects [Name]s blood sugar is high or low or before eating any food. Insulin All pump and diabetic supplies will be kept in the nurses office at all times. A glucagon kit will be kept in the nurses office and in the teachers desk along with a supply of glucose tabs and frosting gel. The nurse will calculate the bolus amount based on the carbohydrate information and bolus and high blood sugar ratios provided by [Name]s parent. The nurse will verify the bolus before [Name] administers it. Field Trips and Extracurricular Activities [Name] will be permitted to participate in all field trips and extracurricular activities without restriction. The teacher will notify [Name]s parents of field trip dates as early as possible. If possible, a parent will accompany [Name] on class field trips. However, a parent will not be required to accompany [Name] on a field trip. If a parent is not able accompany [Name] on a field trip, someone who is qualified to administer all diabetes related care will be provided by the school to accompany [Name]. Tests and Classroom Work [Name] will test his blood glucose prior to criterion reference testing for reporting progress on his report card and enter the meter reading on the top of the page next to his name. If [Name] is affected by high or low blood glucose levels at the time of regular or standardized testing, he will be permitted to take the test at another time without penalty. High blood glucose is defined as over 200 and low is defined as under 70. If [Name] needs to take breaks to use the water fountain or bathroom, perform a blood glucose test, or treat hypoglycemia or hyperglycemia during a test, he will be given extra time to finish without penalty. Similarly, if [Name] needs to take breaks to use the water fountain or bathroom, perform a blood glucose test, or treat hypoglycemia or hyperglycemia during class, he will be given extra time to finish classroom work without penalty. [Name] will not be penalized for absences or tardiness required for medical appointments, illness, visits to the office, or time necessary to maintain blood glucose control. Equal Treatment and Encouragement Encouragement is essential. [Name] must not be treated in a way that discourages him from eating snacks on time or from progressing in doing his own blood glucose tests and general diabetes management. [Name] shall be provided privacy for blood glucose testing and insulin administration if he desires. School staff will keep [Name]s diabetes confidential, except to the extent that [Name] decides to openly communicate about it to others. Parental Notification Notify parent immediately in the following situations: Symptoms of severe low blood sugar such as continuous crying, extreme tiredness or loss of consciousness. [Name]s blood glucose test results are below 70 or below 70 15 min after consuming juice or glucose tabs. Symptoms of severe high blood glucose such as frequent urination, presence of ketones or blood glucose levels above 240. If [Name] refuses to eat or take insulin via injection or pump. In the event of an injury If he is sick If insulin pump becomes disconnected from his body If insulin pump alarms and cant be remedied This plan shall be reviewed and amended at the beginning of each school year or more often if necessary. Signatures and Indication of Agreement: Signature Title Date _______________________ _______________ _________________ _______________________ _______________ _________________ _______________________ _______________ _________________ _______________________ _______________ _________________ _______________________ _______________ _________________ PAGE   PAGE 1 of  NUMPAGES 5 Area of disability that substantially limits a major life activity Type 1 Diabetes Mellitus Description of how this disability limits a major life activity: &'(5@MZ`mrx Hc !67tu$$&& + ++++++++++"+#+-+.+/+0+1+4+{+++++0JmHnHu0J j0JUCJj>*CJUmHnHu >*CJh 5CJhCJh5CJJ'(Z< Q c h &vK h8^ & F & F & F +4++KGHIc N>(;<LQ8# & F & F & F h^h  & Fh^h# !7uvc r!m">#($$$$%)& & F & F & F & F & F)&&&&''m''Q((((())))))))))))) * *J* & FJ*K*****++ ++++1+2+3+4++++++&`#$ 1h/ =!"#$% i<@< NormalCJOJQJ_HmH sH tH >@> Heading 1$@&5CJ OJQJhL@L Heading 2$<@&56CJ\]^JaJ:@: Heading 3$@&5CJ\aJ<A@< Default Paragraph Font>6@> List Bullet 2  & F CJaJ@O@  Balloon TextCJOJQJ^JaJ, @, Footer  !&)@!& Page Number,@2, Header  !''j'(Z<Qch & v K  G H I c N >(;<LQ8# !7uvcrm>( !)""""##m##Q$$$$$%%%%%%%%%%%%% & &J&K&&&&&'' ''1'2'4''''000000000000 0 0 0 0 000 0 0 0 0 0 0 0 0000 0I 0 I 0 I 0I 0 0 0 0 0 0 0 0 0< 0< 0<0<0 000 0 0 000 0 0 0 000 0v 0v 0v 0v0v0 0 0 0 0 00(0 0 0 00*@0@0@0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 000000000000000000000000@@0@0 00 ***-+.K#)&J*+/1234+0 $&-!!TT8@(  V  # " B S  ?'&t _Toc483127448 _Toc483127871 _Toc483130926 _Toc483803847 _Toc483805333 _Toc513692179 _Toc513697045 _Toc513697309 _Toc513697414 _Toc513698050' 'fh"" '3'4''rw mqch '3'4''333333336@OYcmttuuvz.4V\4 : ^ d v | K Q   c i  N T  _eOU$*\`QWJP9?%+^d(.u{pvLR( . !!!!@"F"z""""""""m#s#T$Z$%%%%' '''"'0'' Sean HamblinLC:\WINDOWS\Application Data\Microsoft\Word\AutoRecovery save of jakes%)$.asd Sean Hamblin C:\My Diabetes File\jakes%)$.doc Sean Hamblin+C:\My Diabetes File\Jake's 504\jakes504.doc Sean Hamblin+C:\My Diabetes File\Jake's 504\jakes504.doc Sean HamblinLC:\WINDOWS\Application Data\Microsoft\Word\AutoRecovery save of jakes504.asd Sean Hamblin+C:\My Diabetes File\Jake's 504\jakes504.doc Sean Hamblin+C:\My Diabetes File\Jake's 504\jakes504.docMichael Swaithes:C:\My Documents\diabetes\beverly 504\jakes 504 8-19-02.doc Administrator'C:\Diabetes stuff\jakes 504 8-19-02.docJeff Hitchcock/S:\webroot\cwd\htdocs\504\docs\504_grade4_1.docvs#i ȭ^@` y :Xga.[Ahb :V!,#` I"爒3"{<1#Yh'"4ڒ:'"m:2F:8-<;+D sT@WpouYb5rZh[]>XY(b zc_NdN4h %8֦I ^`OJQJo(h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh hh^h`OJQJo(h 88^8`OJQJo(oh ^`OJQJo(h   ^ `OJQJo(h   ^ `OJQJo(oh xx^x`OJQJo(h HH^H`OJQJo(h ^`OJQJo(oh ^`OJQJo(h^`OJQJo(hHh^`5o(hH.hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHhFF^F`OJQJo(hHh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHh^`OJQJ^Jo(hHohVV^V`OJQJo(hHh&&^&`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh hh^h`OJQJo(h 88^8`OJQJo(oh ^`OJQJo(h   ^ `OJQJo(h   ^ `OJQJo(oh xx^x`OJQJo(h HH^H`OJQJo(h ^`OJQJo(oh ^`OJQJo(h^`OJQJo(hHh^`OJQJ^Jo(hHoh~ ~ ^~ `OJQJo(hHhN N ^N `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^^^^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh~ ~ ^~ `OJQJo(hHhN N ^N `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^^^^`OJQJo(hHh  ^ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh| | ^| `OJQJo(hHhLL^L`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH hh^h`OJQJo(h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh88^8`OJQJo(hHh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHhxx^x`OJQJ^Jo(hHohHH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJo(hHpp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHh^`5o(.h^`5OJQJo(hH pLp^p`LhH. @ @ ^@ `hH. ^`hH. 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