APPENDIX A
DIABETES MANAGEMENT PLAN
Dated:____________________
This plan must be completed by the child´s personal health provider/physician and parents/guardian and immediately updated by these persons with any new information in the future. All entries must be completed or the plan will be deemed incomplete and unsatisfactory. (Please attach additional pages as needed)
(This section to be completed by parents/guardian of child)
1. Effective Dates:______________________________________________________
2. Child´s Name:_______________________________________________________
3. Date of Birth:________________________________________________________
4. Physical Condition (Identify and Explain): ________________________________
___________________________________________________________________
___________________________________________________________________
5. Date of Diagnosis:____________________________________________________
6. Grade: _____________________________________________________________
7. Contact Information: Circle the primary contact person and phone number
Mother/Guardian:_____________________________________________________
Home Address:_____________________________________________________
Employer:_________________________________________________________
Employer´s Address: ________________________________________________
Telephone: Home______________ Work:______________ Cell:_____________
Father/Guardian:_____________________________________________________
Home Address:_____________________________________________________
Employer:_________________________________________________________
Employer´s Address:_________________________________________________
Telephone: Home:______________ Work:_____________ Cell:______________
8. Who has custody of the child? __________________________________________
(This section to be completed by child´s doctor/health care provider)
9. Child´s Doctor/Health Care Provider:
Name:
Address:
Telephone:_________________________________________________________
Emergency Number:_________________________________________________
10. Other Emergency Contacts:
Names:___________________________________________________________
Relationship:_______________________________________________________
Telephone: Home:______________ Work:_______________ Cell:____________
11. Notify parents/guardian or emergency contact in the following situations:________
___________________________________________________________________
___________________________________________________________________
12. Recommended monitoring of child:______________________________________
___________________________________________________________________
___________________________________________________________________
13. Specify any medical time requirements: ___________________________________
___________________________________________________________________
14. Can child perform own monitoring? Yes No
Exceptions: ________________________________________________________
__________________________________________________________________
15. Identify the type of any meter, monitor, nebulizer, applicator, needle, pump, or any other devices necessary for the child´s Medical Management Plan (include model and instruction booklet): _______________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
16. Is the type of blood glucose meter, monitor, nebulizer, or test, necessary for the child´s Medical Management Plan approved by the Federal Food and Drug Administration for over-the-counter sale without a prescription.
Yes
No
Do Not Know
17. What signs does the child demonstrate when child is symptomatic? _____________
___________________________________________________________________
18. Foods to avoid, if any: ________________________________________________
19. Instructions for when food is provided to the child (e.g., as part of a party or food
sampling event): _____________________________________________________
___________________________________________________________________
20. List, identify, and explain any restrictions to exercise, sports, or any other activities:
___________________________________________________________________
___________________________________________________________________
21. Treatment Supplies to be kept at the child care facility and provided by parent/guardian are as follows (please provide specific instructions regarding the storage and treatment of all supplies):_____________________________________
___________________________________________________________________
___________________________________________________________________
22. Provide instructions on the use and handling of monitoring equipment, including lancets, test strips, cotton balls, or other items used while conduction blood glucose tests (must be in accordance with manufacturer´s instructions, if applicable): _________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
23. Provide instructions on how to determine if test results, are within the normal or therapeutic range for the child, and any restrictions on activities or diet: __________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
24. Provide instructions on how to identify symptoms of hypoglycemia or hyperglycemia: ______________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
25. Provide instructions on what actions to take when results are not within the normal or therapeutic range for the child and any restrictions on activities or diet: ____________________________________
___________________________________________________________________
___________________________________________________________________
26. Any specific instructions provided by child´s physician/health care provider relevant to the child´s diabetes care: ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
For children with additional medical concerns, please complete supplemental form.
This Medical Management Plan has been completed and approved by:
I attest that the aforementioned information is true and accurate. I give permission to the Rainbow River Child Development Center to perform and carry out care tasks as outlined in the Medical Management Plan. I also consent to the release of the information contained in this Medical Management Plan to all staff members and other adults who have custodial care of my child such as those persons on the emergency list and who may need to know this information to maintain my child´s health and safety. A written revocation or amendment to this document must be delivered to the aforementioned child care facility by the child´s Parent/Guardian in order to effectuate a revocation of the same. The aforementioned child care facility reserves the right to request additional documentation after review of the within document based on its reasonable discretion, and/or the requirements of California law and the regulations and policies of its state licensing agency, the California Department of Social Services.
Acknowledged, approved and received by:
_________________________
Child´s Parent/Guardian
(Signature)
_______________________________
Telephone Number
_________________________
Child´s Parent/Guardian
(Signature)
_______________________________
Telephone Number
_______________________________
Date
_______________________________
Date