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Run: Diabetes Medical Management Plan and Glucagon Administration Log

Track a student’s diabetes care orders, blood-glucose checks, and any glucagon use in one school health form. Use it to document care, notify guardians, and ...

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Plan Overview and Consent

Student name (required)

Student ID

School name (required)

Grade level

Form purpose (required)

Parent/guardian consent on file for school diabetes care (required)

Yes No N/A

Primary care team contact

Enter only the contact details needed for care coordination.

Diabetes Care Orders

Diabetes type (required)

Blood-glucose monitoring frequency at school (required)

Target blood-glucose range

Low blood-glucose threshold requiring treatment

Enter the numeric threshold from the care plan.

High blood-glucose threshold requiring action

Enter the numeric threshold from the care plan.

Carbohydrate treatment instructions

Document the minimum necessary treatment guidance for low blood glucose.

Insulin administration authorized at school (required)

Insulin instructions

Blood-Glucose Monitoring Log

Date of check (required)

Time of check (required)

Reason for check (required)

Blood-glucose value (required)

Enter the measured value from the meter or continuous glucose monitoring review.

Units (required)

Symptoms observed

Action taken

Document the minimum necessary intervention, such as carbohydrate treatment, recheck, parent/guardian notification, or EMS activation.

Glucagon Administration Event

Date of glucagon administration (required)

Time of glucagon administration (required)

Location of event

Reason glucagon was given (required)

Glucagon product used

Dose administered

Response to glucagon (required)

Document observed response, recheck results, and any follow-up actions.

Emergency medical services called (required)

Notifications, Follow-Up, and Sign-Off

Parent/guardian notified (required)

Notification time

Follow-up needed

Staff name (required)

Staff role (required)

Staff signature (required)

Get your results

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Email (required)

Your name (optional)

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