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]
Area of disability that “substantially limits a major life activity” – Type 1 Diabetes Mellitus
Description of how this disability limits a major life activity:
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[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/she wears an insulin pump. With the help of a qualified adult, [Name] uses his/her insulin pump to administer the correct doses of insulin to match the carbohydrates in the food he/she eats (bolus) and the amount his/her body needs without food (basal rates).
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[Name] also wears a Dexcom G4 PLATINUM (Pediatric) continuous glucose monitor (CGM). Dexcom G4 PLATINUM is a wireless device that reports glucose values every 5 minutes for up to 7 days. The Dexcom CGM provides these sensor glucose values continuously as well as displays glucose trends over time and the direction and speed of glucose change. The Dexcom CGM also has low and high glucose alerts and a severe low glucose alarm that will alert [Name] if he/she is low or high. CGM is a supplement to the blood glucose meter. All treatment decisions should be based on the blood glucose value from the meter.
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[Name]’s basal rates and boluses must be balanced with his/her meals, snacks and regular physical activity. To consistently achieve this balance, he/she must check his/her blood sugar frequently. Depending on the daily classroom schedule, [Name] will need to check his/her blood glucose level before snack, lunch, recess, and before and after physical education class, as well as when his/her body tells his/her blood glucose is low or too high. We will review his/her schedule for checking blood sugar and reviewing their Dexcom CGM prior to the start of each school year and attach a current schedule to this 504 prior to the start of each school year.
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Blood glucose levels must be maintained in the 80-180 range for optimal learning and testing of academic skills.
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[Name]’s behavior is related to blood glucose levels. He/She can feel tired, sluggish and hungry when his/her blood glucose is high and “empty” or “spacey” when it is low.
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When [Name] is excited and/or stressed, as in a testing situation, his/her blood glucose can potentially go up. When his/her blood glucose is high (over 180) his/her body responds by trying to decrease this glucose level. He/She may become thirstier as his/her body is acting to dilute or flush out the extra sugar. He/She 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.
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At least one adult who is qualified to administer all diabetes related care will be available at all times. i.e., nurse or nurse’s designee.
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All teachers will receive a folder containing information regarding [Name]’s care, [Name’s] insulin pump and Dexcom CGM systems, management and emergency procedures.
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The Dexcom receiver should be kept with [Name] at all times or have the receiver within 20 feet of [Name] so the receiver will be able to display his/her glucose trends continuously.
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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.
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Substitute teachers will be given information regarding [Name]’s diabetic care.
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[Name]’s parents will continue to send in all supplies for insulin pump, blood glucose monitoring, Dexcom CGM and keytone monitoring. They will provide juice boxes and complex carbohydrate snacks for treating hypoglycemia.
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[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.
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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/her possession and access to drinking fountain without restriction.
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[Name] shall be permitted to use the bathroom without restriction.
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[Name]’s teacher will notify his/her 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/her 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, sensor glucose readings and boluses given on a daily basis in the chart.
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[Name]’s parent will provide juice boxes and glucose tabs to be kept in the classroom and in the nurse’s office to treat hypoglycemia.
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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.
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School Nutritional staff will supply nutritional information (ie. Carb counts) on all lunch menu items.
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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.
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If [Name] has a hypoglycemic reaction or if his/her Dexcom receiver alerts that [Name] has a low glucose event, he/she is to test his/her 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/she over 80. If [Name] has treated a low, he/she should test again in 15 minutes to confirm he/she is coming back into normal blood sugar range and watch the glucose trend information on the Dexcom receiver. 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.
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[Name] will use the buddy system when out of the classroom and MUST be accompanied by another student or teacher to the nurse’s office. He/She must NEVER be allowed to go to the nurse’s office alone if a low blood sugar is suspected.
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If the nurse is not in the building, the principal, assistant principal, or designated office personnel will have [Name] check his/her blood sugar, review his/her Dexcom CGM, treat him per protocol, and then notify his/her 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.
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If [Name] has a high glucose alert from the Dexcom receiver, [Name] is to show the receiver to the School Staff, then confirm the alert. [Name] will then need to confirm the high alert with their blood glucose meter and treat their hyperglycemia per their medical plan based on the blood glucose value.
Glucose Checks -
The goal is to minimize disruptions in [Name]’s regular school schedule and minimize time away from the classroom.
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Review of the Dexcom receiver and CGM readings and trend arrows should happen frequently throughout the day by [Name] and the School Staff or classroom teacher. If the Dexcom receiver shows impending low glucose, a confirmatory blood glucose meter check will be needed and treatment appropriately per [Name’s] care plan.
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A meter will be kept in the nurse’s office and a vial of insulin will be kept in the nurse’s office refrigerator.
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Glucose checks with their blood glucose meter will be administered any time [Name] feels his/her 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 nurse’s office at all times.
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A glucagon kit will be kept in the nurses’ office and in the teacher’s desk along with a supply of glucose tabs and frosting gel.
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The nurse will calculate the bolus amount based on the carbohydrate information and bolus and high blood sugar ratios provided by [Name]’s parent.
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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.
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The teacher will notify [Name]’s parents of field trip dates as early as possible.
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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.
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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/her blood glucose prior to criterion reference testing for reporting progress on his/her report card and enter the meter reading on the top of the page next to his/her name.
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If [Name] is affected by high or low blood glucose levels at the time of regular or standardized testing, he/she 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.
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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/she will be given extra time to finish without penalty.
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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/she will be given extra time to finish classroom work without penalty.
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[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/her own blood glucose tests and general diabetes management.
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[Name] shall be provided privacy for blood glucose testing, sensor insertion and insulin administration if he/she desires.
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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:
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Symptoms of severe low blood sugar such as continuous crying, extreme tiredness or loss of consciousness.
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[Name]’s blood glucose test results are below 70 or below 70 15 min after consuming juice or glucose tabs.
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Symptoms of severe high blood glucose such as frequent urination, presence of ketones or blood glucose levels above 240.
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If [Name] refuses to eat or take insulin via injection or pump.
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In the event of an injury
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If he/she is sick
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If insulin pump becomes disconnected from his/her body
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If insulin pump alarms and can’t be remedied
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If the Dexcom sensor falls off his/her body
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If the Dexcom receiver alarms or has an alert/alarm that cannot be resolved.
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
_______________________ _______________ _________________
_______________________ _______________ _________________
_______________________ _______________ _________________
_______________________ _______________ _________________
_______________________ _______________ _________________
Disclaimer: This 504 plan is a sample plan that can be used as a foundation for an individual 504 plan parents, patients and healthcare providers develop together collaboratively. This sample 504 plan is not meant to offer any medical advice.
LBL012461 Rev 01
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