Student DOB School Grade Equipment Daily Snacks (for AM/PM snack times) Specify: Insulin Supplies and supplies to be provided by parent Insulin pen Insulin and syringes Extra pump supplies such as: Vial of insulin, syringes Blood Glucose Meter Kit Pump syringe (Includes meter, testing strips, lancing device Pump tubing/needle with lancet, cotton balls, spot Band-Aids, alcohol Batteries prep pads) Brand/Model: Tape Sof-Serter Insulin supplies stored: Low Glucose Supplies, Fast Acting Carbohydrate Drinks: (Apple juice and/or orange juice, sugared soda pop-NOT diet), at least 6 containers. Emergency Supplies Glucose Tablets, 1 package or more. Glucagon: YES or NO Glucose Gel Products Note: Do not use if student is having Kit stored: difficulty swallowing Gel Cakemate 3 day disaster food supply stored: Do not use if student is having Note: difficulty swallowing. Prepackaged Snacks (such as crackers with cheese or peanut butter, nite bite, School may include a copy of the IHP for etc.), 5 - 6 servings or more. Diabetes Management with the Disaster Supplies. Stored as follows: High Blood Glucose Supplies Ketone Test Strips/Bottle Urine cup Other Supplies and Special Needs Water bottle Protein Snack (Meat or cheese sticks) EMERGENCY ACTION PLAN SECTION III (Individualize to Student According to Physician’s Orders)
Student DOB School Grade Equipment and supplies to be provided by parent Daily Snacks (for AM/PM snack times) Specify: Blood Glucose Meter Kit (Includes meter, testing strips, lancing device with lancet, cotton balls, spot Band-Aids, alcohol prep pads) Brand/Model: Low Glucose Supplies, Fast Acting Carbohydrate Drinks: (Apple juice and/or orange juice, sugared soda pop-NOT diet), at least 6 containers. Glucose Tablets, 1 package or more. Glucose Gel Products Note: Do not use if student is having difficulty swallowing Gel Cakemate Note: Do not use if student is having difficulty swallowing. Prepackaged Snacks (such as crackers with cheese or peanut butter, nite bite, etc.), 5 - 6 servings or more. High Blood Glucose Supplies Ketone Test Strips/Bottle Urine cup Water bottle Protein Snack (Meat or cheese sticks) Insulin Supplies Insulin pen Insulin and syringes Extra pump supplies such as: Vial of insulin, syringes Pump syringe Pump tubing/needle Batteries Tape Sof-Serter Insulin supplies stored: Emergency Supplies Glucagon: YES or NO Kit stored: 3 day disaster food supply stored: School may include a copy of the IHP for Diabetes Management with the Disaster Supplies. Stored as follows: Other Supplies and Special Needs EMERGENCY ACTION PLAN SECTION III (Individualize to Student According to Physician’s Orders)
IHP%20Diabetes%207.29.16.docx