504 Plan for the School Year _______

Student Name:______________ Date of Birth: __________

School:________________ Grade:______

 ________ has type I 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, she wears
an insulin pump. ______ uses her insulin pump to administer the correct doses of
insulin to match the carbohydrates in the food she eats (bolus) and the amount her
body needs without food (basal rates).

 Type 1 diabetes is a recognized disability that requires the accommodations and

modifications set out in this plan to ensure that she has the same opportunities and
conditions for learning and academic testing as classmates, with minimal disruption
of her regular school schedule and with minimal time away from the classroom.

 _______’s basal rates and food boluses must be balanced with her meals, snacks
and regular physical activity. To consistently achieve this balance, she must check
her blood sugar frequently. Depending on the daily classroom schedule, _____ will
need to check her blood glucose level before snack, lunch, recess, and before and
after physical education class, as well as when her body tells her blood glucose is
low or too high. We will review her schedule for checking blood sugar and attach a
current schedule to this 504 prior to the start of each school year.

 _____ also wears a continuous glucose monitor which tests the glucose level in the
interstitial fluid throughout the day. This monitor will alert (beep) when _____'s
glucose is too high (2 beeps), too low (3 beeps) or going down quickly (3 beeps).

 While _____ is beginning to achieve independence in self-management of her

diabetes, the adults who work with her will need to be supportive and understanding
about the daily regimen. Her self-care needs will be integrated into the school day so
there are minimal interruptions in the learning environment.

 Blood glucose levels must be maintained in the 80-180 range for optimal learning
and testing of academic skills.

 ______'s behavior is often directly related to her blood glucose levels. She can feel
grumpy, angry, tired and sluggish when her blood glucose is high. She feels hungry
when it is low. She can appear "out of it" when her blood glucose is low. When her
blood glucose is either high, low, or changing rapidly, she can be more emotional
than normal and/or appear angry or grumpy.

 When _____ is excited and/or stressed, as in a testing situation, her blood glucose
can potentially go up. When her blood glucose is high (over 180) her body responds
 by trying to decrease this glucose level. She may become thirstier as her body is
acting to dilute or flush out the extra sugar. She needs to drink more water and then
urinate more frequently.

 An adult and back up adult(s) should be trained to 1) perform blood glucose

monitoring and record the results; 2) take appropriate actions for blood glucose
levels outside the target ranges as indicated in _____'s diabetes health care plan; 3)
test the urine or blood for ketones when necessary and respond to the results of this
test; 4) be trained in the administration of insulin and glucagon; 5) be responsible for
_____ and know the schedule of her meals and snacks and; 6) work closely with her
parents to coordinate this schedule with that of the other students as closely as
possible. This individual will also notify her parents in advance of any expected
changes in the school schedule that effect _____'s meal times or exercise routines.

 _____'s parents will be happy to assist in the education on type 1 diabetes, which
will include but is not limited to, instructional videos and literature.

Information/Communication
 All teachers will be notified each year that ______ has diabetes and will be
instructed on what to do in the event of a hypoglycemic reaction. ______'s
parents will provide information sheets for each teacher who works with _____.

 If a concern arises regarding _____’s health or academic progress as affected by

diabetes, there will be no hesitation to arrange a meeting among appropriate
school personnel and parents.

 Teacher’s sub folder will contain information regarding _____’s diabetes.

 _____'s parents will continue to send in all supplies for insulin pump, blood
glucose monitoring, and ketone monitoring. They will provide juice boxes and
complex carbohydrate snacks for treating hypoglycemia.

 The nurse will notify _____’s parents when supplies are getting low.

Water and bathroom access

 _____ shall be permitted to have access to water at all times, including keeping a
water bottle in her possession.

 ______ shall be permitted to use the bathroom without restriction.

 _____’s teacher will notify her parents if drinking or bathroom frequency seems
excessive.
Snacks and Meals
 _____’s parents will provide information listing the appropriate information for
correcting high blood sugar (ISF or insulin sensitivity factor) and the amount of
insulin bolus required for various carbohydrate in her meal or snack (food
carbohydrates and carbohydrate ratios). _____’s parents will also provide a
notebook for daily communication with the school nurse. The notebook will
include the carbohydrate amounts in ______’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 notebook.

 _____ will report to the clinic and have her blood glucose checked before lunch.

 _____ will be permitted enough time to finish her snack/meal.

 _____ will be monitored at snack and lunchtime to ensure she finishes her meal
or snack.

 Immediately after eating, _____ will take her lunch/snack to the clinic so that the
nurse can count the carbohydrates consumed and bolus accordingly.

 The teacher will give _____’s parents advance notice of classroom parties or
food.

 The teacher will check with the nurse before giving any extra snacks that might
have been brought in by other students, such as with birthdays.

 All school personnel will permit _____ to eat a snack in the classroom or
wherever _____ is (including, but not limited to classrooms, gym, auditorium,
playground, field trips, and school bus) whenever needed to treat hypoglycemia.

Low Blood Sugar

 When low blood sugar is suspected, _____ must not be left alone. In the
event of suspected low blood sugar, an adult, not a student, must
accompany her to the nurse. The nurse will treat her blood sugar in
accordance to the physician protocol.

 _____'s parents will be notified of any low blood sugar.

 _____ will use the buddy system when out of the classroom.

 ______ will keep a supply kit in her classroom that contains a blood glucose
meter, glucagon, juice box, and other snacks to treat a low blood sugar. This kit
will be provided by _____'s parents. This kit MUST accompany her every time
 she leaves the classroom including but not limited to special area classes,
recess, literacy lab, the cafeteria and the restroom.

 During a fire/tornado/lockdown situation, _____'s kit MUST accompany her from

the building and/or to the safe spot.

High Blood Sugar

 High blood sugar will be monitored closely and treated per 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 _____’s regular school schedule and
minimize time away from the classroom.

 A extra blood glucose meter will be kept in the classroom and in the nurse’s
office.

 _____'s blood glucose will be checked when her cgm alerts that she either too
high, too low, or dropping rapidly.

 Glucose checks will be administered according to the times in the medical

protocol, any time _____ feels her blood sugar may be high or low, and/or any
time an adult suspects _____’s blood sugar is high or low.

Insulin
 All pump supplies will be kept in the nurse’s office.

 The nurse will calculate the bolus amount based on the carbohydrate
information, carbohydrate ratios, and insulin sensitivity factors provided by
_____ ’s parents.

Field Trips and Extracurricular Activities

 ______ will be permitted to participate in all field trips and extracurricular
activities without restriction.

 The teacher will notify _____'s parents of field trip dates as early as possible.

 If possible, a parent will accompany _____ on class field trips.

  If a parent is not able accompany _____ on a field trip, a nurse or someone who
is qualified to administer all diabetes related care will accompany _____.

Tests and Classroom Work

 _____ will have access to school nurse whenever necessary and without
restriction.

 If _____ is affected by high or low blood glucose levels at the time of regular or
standardized testing, she will be permitted to take the test at another time without
penalty.

 If _____ needs to take breaks to use the water fountain or bathroom, perform a
blood glucose test, or treat hypoglycemia or hyperglycemia during a test, she will
be given extra time to finish without penalty.

 Similarly, If _____ needs to take breaks to use the water fountain or bathroom,
perform a blood glucose test, or treat hypoglycemia or hyperglycemia during
class, she will be given extra time to finish classroom work without penalty.

 _____ 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.

This plan shall be reviewed and amended at the beginning of each school year or more
often if necessary.

Signatures and Indication of Agreement:

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