504, Chapter 15 Protected Handicapped Students

[Name] 504, Chapter 15 Protected Handicapped Students Service Agreement

Accommodations

1. Kindergarten assignment in the morning class. (Nurse is only in school building until 11 AM on Tuesdays and Thursdays.)

2. Two adults will be trained in administration of medication and blood glucose testing and testing for ketones when necessary. One trained adult will be available in the building or on field trips to address [Name]’s medical needs. Parents will provide training prior to the first student day. Training will include administration of medication, which involves knowing how to perform insulin boluses using [Name]’s pump and knowing how to administer both insulin and glucagon via injection in the event of a medical emergency.

3. Parents will supply medication dosage and update it as often as needed. This information will be provided prior to the first student day.

4. Parents will provide a test kit that will be kept by the supervising staff member with [Name] for her use (classroom, playground, field trips. etc.) [Name] will have her diabetes kit (purple bag) immediately accessible; the supervising staff member is responsible for ensuring that [Name]’s kit goes wherever she goes (until such a time when she is developmentally capable of assuming said responsibility). In addition, supervising staff members will know how and when to use the contents of her kit: blood glucose meter, fast-acting glucose (juice, fruit snacks) and cake gel icing to be used to smear her gums in the event that [Name] can’t drink juice because of a low blood glucose level.

5. Students in [Name]’s class will be given specific direction about her equipment (e.g., no student is to touch her pump, its casing or its tubing).

6. [Name] will test her blood glucose level before any criterion reference testing for reporting progress on her report card. If her blood glucose does not fall in the normal range (is less than 80 or greater than 150) corrective measures must be taken. [Name] must have the opportunity to delay the assessment until her blood glucose levels fall within the normal range. She will be given the same amount of time allotted to the other students to complete the assessment.

7. A trained adult will monitor the quantity of food [Name] eats during snack time and lunch for carbohydrate amounts so the insulin bolus can be administered according to the insulin/carbohydrate ratios provided by the parents. Parents will also provide carbohydrate and bolusing information on any food [Name] brings to school and for snacks commonly eaten. Father will be contacted at [phone] when there is any type of party.

8. During field trips, parents will be given the option to attend. In the event they are unable to attend, a trained adult will be assigned to monitor [Name]. 9. Parents must be contacted for any of the following reasons: [Name]’s infusion set comes out (insulin pump no longer connected to her body), her pump alarms and cannot be remedied, her blood sugar is less that 50, her blood sugar is less than 75 on two consecutive readings, her blood glucose exceeds 300, her blood glucose exceeds 250 on two consecutive readings.

10. The teacher will provide a spot in the classroom for blood testing. Additionally, [Name] will be permitted to test or have someone test her blood glucose in any other location of the school or outside of the school building if a low blood glucose is suspected. Parents will provide training as well as informational charts (for classrooms) and cards (for her test kit) detailing how to identify a low (or high) blood sugar. [Name] will not be limited as to the number of blood glucose tests performed per day.

11. [Name] will wear a medic alert bracelet at all times.

12. If [Name] behaves in a manner that is out of character (i.e. disrespectful/ belligerent/ defiant; hard time staying in her seat; sleepy, lethargic) then her blood glucose must immediately be taken. Blood glucose level should fall within normal range before disciplinary action is taken.

Contact Information

Father: Name Address Phone Cell Phone Pager

Mother: Name Address Phone Cell Phone Pager

Doctor: Name Address Phone