, but not limited to, blood glucose testing, responding to hyperglycemia and
hypoglycemia, providing snacks and access to water and the bathroom, and
administering insulin and glucagon).
Either a DCAP or an ADCP will be available at the site of all extracurricular activities that
take place on school premises. An ADCP must be on the school premises whenever the
student is present.
The student’s diabetes supplies will travel with the student to any field trip or
extracurricular activity on or off of school premises.
TESTS AND CLASSROOM WORK
1. If the student is affected by high or low blood glucose levels at the time of regular
testing, the student will be permitted to take the test at another time without
2. If the student needs to take breaks to use the water fountain or bathroom, do a
blood glucose test, or to treat hypoglycemia or hyperglycemia during a test, the
student will be given extra time to finish the test without penalty.
3. The student will be permitted to have extra time to finish classroom work if the
student is affected by high or low blood glucose levels or needs to take breaks to
use the water fountain or bathroom, do a blood glucose test, or to treat
hypoglycemia or hyperglycemia without penalty.
4. The student shall be given instruction to help him/her make up any classroom
time missed due to diabetes care without penalty.
5. The student shall not be penalized for absences required for medical
appointments and/or for illness.
1. An ADCP or DCAP will notify parent/guardian 3 days in advance when there will
be a change in planned activities such as exercise, playground time, fieldtrips,
parties, or lunch schedule, so that the lunch or snack plan can be adjusted
2. The parent/guardian may send the ADCP special instructions regarding the
snack, snack time, or other aspects of the student’s diabetes care in response to
changes in the usual schedule.
3. An ADCP must provide any substitute teacher with written instructions regarding
the student’s diabetes care and a list of all ADCPs and DCAPs at the school.
EQUAL TREATMENT AND ENCOURAGEMENT
1. Encouragement is essential. The student must not be treated in a way that
discourages the student from eating snacks on time, or from progressing in doing
his/her own blood glucose tests and general diabetes management.
2. The student shall be provided with privacy for blood glucose testing and insulin
administration if the student desires.
ADCPs, DCAPs, BDDCPs, and other staff will keep the student’s diabetes confidential,
except to the extent that the student decides to openly communicate about it with others.
NOTIFY PARENTS/GUARDIANS IMMEDIATELY IN THE FOLLOWING SITUATIONS:
* Symptoms of severe low blood sugar such as continuous crying, extreme tiredness, or
loss of consciousness.
*The student’s blood glucose test results are below 70 or are below 80, 15 minutes after
consuming juice or glucose tablets.
*Symptoms of severe high blood sugar such as frequent urination, presence of ketones
or blood glucose level above 400.
*The student refuses to eat or take insulin injection.
*Other: Any reason you feel you need to contact Mom (Cell: [phone]).
EMERGENCY CONTACT INSTRUCTIONS
1. Call the student’s mother at work. If unable to reach parent/guardian:
2. Call the student’s parent/guardian’s cell or work phone. If unable to reach
3. Call [name] at [number]
4. Call [name] at [location]
Other emergency contacts:
[name, address, phone]
This Plan shall be reviewed and amended at the beginning of each school year or more
often if necessary.
Physician Signature & Date
School Representative and Title Date