Diabetes Medical Management Plan (DMMP) 

This plan should be completed by the student’s personal diabetes health care team, including the parents/guardian. It should be reviewed with relevant school staff and copies should be kept in a place that can be accessed easily by the school nurse, trained diabetes personnel, and other authorized personnel.
Date of Plan:	 This plan is valid for the current school year:_____ - _____
Student's Name: 	Date of Birth: 	____________
Date of Diabetes Diagnosis: _____________   type 1    type 2  Other_________
School: 	School Phone Number: 		
Grade:	Homeroom Teacher:
School Nurse:	Phone:
CONTACT INFORMATION Mother/Guardian: 	 Address:
Telephone: Home	 Work	Cell:	 Email Address:
Father/Guardian:
Address:
Telephone: Home	 Work	Cell:	 Email Address:
Student's Physician/Health Care Provider: Address:

Telephone:

Email Address:	Emergency Number:

Other Emergency Contacts: 
Name:	 Relationship:_________	
Telephone: Home	 Work		Cell:______________

Diabetes Medical Management Plan (DMMP) — Page 2
CHECKING BLOOD GLUCOSE
Target range of blood glucose:	70-130 mg/dL     70-180 mg/dL
 Other: 	
Check blood glucose level:  Before lunch 	Hours after lunch
 2 hours after a correction dose   Mid-morning   Before PE	   After PE
 Before dismissal    Other:	
 As needed for signs/symptoms of low or high blood glucose
 As needed for signs/symptoms of illness
Preferred site of testing:   Fingertip  Forearm  Thigh  Other: 	
Brand/Model of blood glucose meter:	
Note: The ,fingertip should always be used to check blood glucose level if hypoglycemia is suspected.
Student's self-care blood glucose checking skills:
 Independently checks own blood glucose
 May check blood glucose with supervision
 Requires school nurse or trained diabetes personnel to check blood glucose 

Continuous Glucose Monitor (CGM):  Yes  No
Brand/Model: _____________________	Alarms set for: (low) and (high)

Note: Confirm CGM results with blood glucose meter check before taking action on sensor blood glucose level. If student has symptoms or signs of hypoglycemia, check fingertip blood glucose level regardless of CGM
HYPOGLYCEMIA TREATMENT
Student's usual symptoms of hypoglycemia (list below):
If exhibiting symptoms of hypoglycemia, OR if blood glucose level is less than
	mg/dL, give a quick-acting glucose product equal to	grams of carbohydrate.
Recheck blood glucose in 10-15 minutes and repeat treatment if blood glucose level is less than	mg/dL.
Additional treatment:

Diabetes Medical Management Plan (DMMP) — Page 3 HYPOGLYCEMIA TREATMENT (Continued)
Follow physical activity and sports orders (see page 7).
•	If the student is unable to eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions (jerking movements), give:
•	Glucagon:  1 mg   1/2 mg	Route:  SC  IM
•	Site for glucagon injection:   arm   thigh   Other: ___________________	
•	Call 911 (Emergency Medical Services) and the student's parents/guardian.
•	Contact student's health care provider.
HYPERGLYCEMIA TREATMENT
Student's usual symptoms of hyperglycemia (list below):
Check   Urine   Blood for ketones every	hours when blood glucose levels
are above	mg/dL.
For blood glucose greater than	mg/dL AND at least	hours since last insulin
dose, give correction dose of insulin (see orders below).
For insulin pump users: see additional information for student with insulin pump.
Give extra water and/or non-sugar-containing drinks (not fruit juices):	ounces per
hour.
Additional treatment for ketones:
Follow physical activity and sports orders (see page 7).
•	Notify parents/guardian of onset of hyperglycemia.
•	If the student has symptoms of a hyperglycemia emergency, including dry mouth, extreme thirst, nausea and vomiting, severe abdominal pain, heavy breathing or shortness of breath, chest pain, increasing sleepiness or lethargy, or depressed level of consciousness: Call 911 (Emergency Medical Services) and the student's parents/
guardian.
•	Contact student's health care provider.

Diabetes Medical Management Plan (DMMP) — page 4
INSULIN THERAPY
Insulin delivery device:   syringe     insulin pen    insulin pump
Type of insulin therapy at school:
 Adjustable Insulin Therapy
 Fixed Insulin Therapy
 No insulin
Adjustable Insulin Therapy
•	Carbohydrate Coverage/Correction Dose: Name of insulin:
•	Carbohydrate Coverage: Insulin-to-Carbohydrate Ratio:
 Lunch: 1 unit of insulin per		grams of carbohydrate
 Snack: 1 unit of insulin per		grams of carbohydrate

Grams of carbohydrate in meal
Insulin-to-carbohydrate ratio

Carbohydrate Dose Calculation Example 
             
                               =  ______ units of insulin    	
•	Correction Dose:

Correction Dose Calculation Example Actual Blood Glucose—Target Blood Glucose

Blood Glucose Correction Factor/Insulin Sensitivity Factor = Target blood glucose =          mg/dL

Blood Glucose Correction Factor/Insulin Sensitivity Factor

= _______units of insulin

Correction dose scale (use instead of calculation above to determine insulin correction dose):
Blood glucose	to	mg/dL	give	units	
Blood glucose	to	mg/dL	give	units	
Blood glucose	to	mg/dL	give	units	
Blood glucose	to	mg/dL	give	units	

Diabetes Medical Management Plan (DMMP) — page 5 INSULIN THERAPY (Continued)
When to give insulin:
Lunch
 Carbohydrate coverage only
 Carbohydrate coverage plus correction dose when blood glucose is greater than
   	mg/dL and	hours since last insulin dose.
 Other: 	
Snack
 No coverage for snack
 Carbohydrate coverage only
 Carbohydrate coverage plus correction dose when blood glucose is greater than
   	mg/dL and	hours since last insulin dose.
 Other: 	

 Correction dose only:
For blood glucose greater than	mg/dL AND at least	hours since last insulin dose.
 Other: 	
Fixed Insulin Therapy Name of insulin:
	Units of insulin given pre-lunch daily
	Units of insulin given pre-snack daily
 Other: 	
Parental Authorization to Adjust Insulin Dose:
 Yes	 No 	Parents/guardian authorization should be obtained before                   
                     administering a correction dose.
 Yes		 No 	Parents/guardian are authorized to increase or decrease correction
                     dose scale within the following range: +/-	units of insulin.
 Yes		No 	Parents/guardian are authorized to increase or decrease insulin-to‑
                     carbohydrate ratio within the following range:	units
                     per prescribed grams of carbohydrate, +/-	grams of carbohydrate.
 Yes		 No 	Parents/guardian are authorized to increase or decrease fixed insulin
                    dose within the following range: +/-	units of insulin.

Diabetes Medical Management Plan (DMMP) — page 6 INSULIN THERAPY (Continued)
Student's self-care insulin administration skill
 Yes  No	Independently calculates and gives own injections 
 Yes	 No	May calculate/give own injections with supervision
 Yes	 No	Requires school nurse or trained diabetes personnel to calculate/give 
         injections

ADDITIONAL INFORMATION FOR STUDENT WITH INSULIN PUMP 
Brand/Model of pump:	 Type of insulin in pump: ______________
Basal rates during school: ____________________________________________________
Type of infusion set: ________________________________________________________
 For blood glucose greater than	mg/dL that has not decreased within
    	hours after correction, consider pump failure or infusion site failure. Notify 
    parents/guardian.
 For infusion site failure: Insert new infusion set and/or replace reservoir.
 For suspected pump failure: suspend or remove pump and give insulin by syringe or 
    pen.
Physical Activity
May disconnect from pump for sports activities  Yes   No
Set a temporary basal rate  Yes   No	% temporary basal for       hours
Suspend pump use  Yes   No

Student's self-care pump skills: 	Independent?
Count carbohydrates	 Yes  No	
Bolus correct amount for carbohydrates consumed 	 Yes  No
Calculate and administer correction bolus	 Yes  No
Calculate and set basal profiles	 Yes  No
Calculate and set temporary basal rate 	 Yes  No
Change batteries	 Yes  No
Disconnect pump	 Yes  No
Reconnect pump to infusion set 	 Yes  No
Prepare reservoir and tubing	 Yes  No
Insert infusion set	 Yes  No
Troubleshoot alarms and malfunctions	 Yes  No

Diabetes Medical Management Plan (DMMP) — page 7 
OTHER DIABETES MEDICATIONS
Name: 	Dose:	Route: 	Times given: ______
Name: 	Dose:	Route: 	Times given: ______

Meal/Snack	Time	Carbohydrate Content (grams)
Breakfast	___________________	_________ to	
Mid-morning snack	___________________	_________ to	
Lunch	___________________	_________ to		
Mid-afternoon snack	___________________	_________ to	

MEAL PLAN

Other times to give snacks and content/amount:
Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event): 	
Special event/party food permitted:  Parents/guardian discretion
	 Student discretion
Student's self-care nutrition skills:
 Yes  No Independently counts carbohydrates
 Yes  No May count carbohydrates with supervision
 Yes  No Requires school nurse/trained diabetes personnel to count carbohydrates
PHYSICAL ACTIVITY AND SPORTS
A quick-acting source of glucose such as  glucose tabs and/or  sugar-containing juice must be available at the site of physical education activities and sports.
Student should eat 15 grams  30 grams of carbohydrate  other	
 before   every 30 minutes during   after vigorous physical activity
 other	
If most recent blood glucose is less than	mg/dL, student can participate in
physical activity when blood glucose is corrected and above	mg/dL.
Avoid physical activity when blood glucose is greater than	mg/dL or if urine/
blood ketones are moderate to large.
(Additional information for student on insulin pump is in the insulin section on page 6.)

Diabetes Medical Management Plan (DMMP) — page 8
DISASTER PLAN
To prepare for an unplanned disaster or emergency (72 HOURS), obtain an emergency supply kit from parent/guardian.
 Continue to follow orders contained in this DMMP.
 Additional insulin orders as follows: 	
 Other: 	
SIGNATURES
This Diabetes Medical Management Plan has been approved by:
Student's Physician/Health Care Provider	Date
I, (parent/guardian:)	give permission to the school nurse
or another qualified health care professional or trained diabetes personnel of
(school:)	to perform and carry out the diabetes care
tasks as outlined in (student:)	's Diabetes Medical Management Plan. I also consent to the release of the information contained in this Diabetes Medical Management Plan to all school staff members and other adults who have responsibility for my child and who may need to know this information to maintain my child's health and safety. I also give permission to the school nurse or another qualified health care professional to contact my child's physician/health care provider.
Acknowledged and received by:

Date
Date
Date

Student's Parent/Guardian
Student's Parent/Guardian
School Nurse/Other Qualified Health Care Personnel