SAMPLE 504 Plan
SECTION 504 PLAN
The attached sample Section 504 Plan was developed by the American Diabetes Association (ADA) and the Disability Rights Education and Defense Fund, Inc. (DREDF). For further information, see the ADA Position Statement, ďCare of Children with Diabetes in the School and Day Care Setting.Ē (Diabetes Care, Volume 25, Supplement 1, January 2002).
Section 504 Plan for ___________________
School Year: _________________
Studentís Name __________________
Birth Date _____________________
Homeroom Teacher __________________
Bus Number _________________________
The student has type ____ diabetes. Diabetes is a serious, chronic disease that impairs the bodyís ability to use food. Insulin, a hormone produced by the pancreas, helps the body convert food into energy. In people with diabetes, either the pancreas doesnít make insulin or the body cannot use insulin properly. Without insulin, the bodyís main energy source Ė glucose Ė cannot be used as fuel. Rather, glucose builds up in the blood. Over many years, high blood glucose levels can cause damage to the eyes, kidneys, nerves, heart and blood vessels.
The majority of school-aged youth with diabetes have type 1 diabetes. People with type 1 diabetes do not produce insulin and must receive insulin through either injections or an insulin pump. Insulin taken in this manner does not cure diabetes and may cause the studentís blood glucose level to become dangerously low. Type 2 diabetes, the most common form of the disease typically afflicting obese adults, has been shown to be increasing in youth. This may be due to the increase in obesity and decrease in physical activity in young people. Students with type 2 diabetes may be able to control their disease through diet and exercise alone or may require oral medications and/or insulin injections. All people with type 1 and type 2 diabetes must carefully balance food, medications, and activity level to keep blood glucose levels as close to normal as possible.
Low blood glucose (hypoglycemia) is the most common immediate health problem for students with diabetes. It occurs when the body gets too much insulin, too little food, a delayed meal, or more than usual amount of exercise. Symptoms of mild to moderate hypoglycemia include tremors, sweating, lightheadedness, irritability, confusion and drowsiness. A student with this degree of hypoglycemia will need to promptly ingest carbohydrates and may require assistance. Severe hypoglycemia, which is rare, may lead to unconsciousness and convulsions and can be life threatening if not treated promptly.
High blood glucose (hyperglycemia) occurs when the body gets too little insulin, too much food or too little exercise; it may also be caused by stress or an illness such as a cold. The most common symptoms of hyperglycemia are thirst, frequent urination, and blurry vision. If untreated over a period of days, hyperglycemia can cause a serious condition called diabetic ketoacidosis (DKA) characterized by nausea, vomiting and a high level of ketones in the urine. For students using insulin infusion pumps, lack of insulin supply may lead to DKA in several hours. DKA can be life-threatening and, thus, requires immediate medical attention.
Accordingly, for the student to avoid the serious short and long term complications of blood sugar levels that are either too high or too low, this Section 504 Plan, and the accompanying Health Plan, must be carefully followed and strictly adhered to by responsible school personnel. To facilitate the appropriate care of the student with diabetes, school and day care personnel must have an understanding of diabetes and be trained in its management and in the treatment of diabetes emergencies. Knowledgeable trained personnel are essential if the student is to avoid the immediate health risks of low blood glucose and to achieve the metabolic control required to decrease risks for later development of diabetes complications.
OBJECTIVE/GOALS OF THIS PLAN
Both high blood sugar levels and low blood sugar levels affect the studentís ability to learn as well as seriously endangering the studentís health. Blood glucose levels must be maintained in the ________________ range for optimal learning and testing of academic skills. The student has a recognized disability, type __ diabetes, that requires the accommodations and modifications set out in this plan to ensure that the student has the same opportunities and conditions for learning and academic testing as classmates, with minimal disruption of the studentís regular school schedule and with minimal time away from the classroom. Steps to prevent hypoglycemia and hyperglycemia, and to treat these conditions if they occur, must be taken in accordance with this Plan and with the studentís Health Care Plan, which is attached to this Section 504 Plan and incorporated into it.
DEFINITIONS USED IN THIS PLAN
1. Diabetes Care Provider (DCP): A staff member who has received training in the care of individuals with diabetes from a health care professional with expertise in diabetes, unless the studentís health care provider determines that the parent/guardian is able to provide the school personnel with sufficient oral and written information to allow the school to have a safe and appropriate environment for the child, in which case the parent/guardian may provide this training. This training shall include instruction in:
∑ the unassisted administration of glucagon and insulin shots and recording of results;
∑ understanding physician instructions concerning drug dosage, frequency, and manner of administration;
∑ applicable state regulations concerning drug storage, security, and record-keeping;
∑ symptoms of hypoglycemia and hyperglycemia and the time within which glucagon or insulin shots are to be administered to prevent adverse consequences;
∑ recommended schedules and menus for meals and snacks, recommended frequency of and activities in exercise periods, and actions to take if normal schedule is disrupted.
∑ performing finger-stick blood glucose testing, urine ketone testing, and recording the results; and
∑ the appropriate steps to take when glucose level results are outside of the target ranges indicated in the studentís Health Care Plan.
2. Diabetes Care Assistant Provider (DCAP): A staff member who has received training from a health care professional with expertise in diabetes, a DCP, or the studentís parent/guardian (if the studentís health care provider determines that the parent/guardian is able to provide the school personnel with sufficient oral and written information to allow the school to have a safe and appropriate environment for the child). This training shall include instruction in:
∑ recognizing the symptoms of hypoglycemia and hyperglycemia;
∑ knowing the proper method for referring a student who exhibits symptoms of hypoglycemia or hyperglycmeia to a DCP; and
∑ recommended schedules and menus for meals and snacks, recommended frequency of and activities in exercise periods, and actions to take if normal schedule is disrupted.
3. Bus Driver Diabetes Care Provider (BDDCP): A bus driver who has received training by a health care professional with expertise in diabetes, a DCP, or the studentís parent/guardian (if the studentís health care provider determines that the parent/guardian is able to provide the school personnel with sufficient oral and written information to allow the school to have a safe and appropriate environment for the child). This training shall include instruction in:
∑ recognizing the symptoms of hypoglycemia and hyperglycemia; and
∑ knowing the appropriate steps to take when glucose levels are creating emergency conditions.
4. Health Care Plan: A plan developed under Section 504 of the Rehabilitation Act of 1973, the Americans With Disabilities Act of 1990, and, as appropriate, the Individuals With Disabilities Education Act (IDEA), that identifies the health care needs of ó and services to be provided to ó a student with diabetes. This plan is approved by the studentís treating physician.
1. HEALTH CARE SUPERVISION
1.1. At least _______ adult staff members will receive training to be an Diabetes Care Provider (DCP), and a DCP will be available at all times during school hours, during extracurricular activities, and on field trips to oversee the studentís health care in accordance with this Section 504 Plan and the studentís Health Care Plan, including performing or overseeing insulin injections, blood glucose tests, ketone tests, and responding to hyperglycemia and hypoglycemia including administering glucagon. A written back-up plan will be implemented to ensure that a DCP is available in the event that the primary DCP is unavailable.
1.2. Any staff member who has primary care for the student at any time during school hours, extracurricular activities, or during field trips, and who is not a DCP, shall receive training to be a DCAP. Primary care means that the staff member is in charge of a class or activity in which the student participates.
1.3. Any bus driver who transports the student when neither a DCP nor DCAP is present must be a BDDCP.
2. TRAINED PERSONNEL
2.1 The following school staff members (including but not limited to school administrators, teachers, counselors, health aides, cafeteria and library staff) will be trained to become Diabetes Care Providers (DCPs) by _________________ (date):
2.2 The following School staff members (including but not limited to school administrators, teachers, counselors, health aides, cafeteria and library staff) will be trained to become Diabetes Care Assistant Providers (DCAPs) by __________________________ (date):
2.3 The following bus drivers will be trained to become Bus Driver Diabetes Care Providers (BDDCP) by __________________________ (date):
3 STUDENTíS LEVEL OF SELF-CARE
The studentís current ability to perform various diabetes self-management skills is indicated by activities check in the chart
Anser all Yes/No/N/A
Totally independent management (only requires adult assistance during severe hypoglycemia) _________
Student tests blood glucose level independently ________
Student needs verification of blood glucose number by (circle one or both) DCP DCAP ________
Blood glucose testing to be done by DCP _____________
Student administers insulin independently _______
Student self-injects insulin with verification of dosage by (circle one or both) DCP DCAP _______
Insulin injections to be done by DCP ________________
Student self-treats mild hypoglycemia _____________
Student requires assistance to treat mild hypoglycemia from:
(circle one or both) DCP DCAP _________
Student monitors own snacks and meals __________
Snacks and meals to be supervised by: (circle one or both) DCP DCAP ________
Student tests and interprets own urine ketones _________
Urine ketones to be tested by DCP: ________
Student implements universal precautions _________
Universal precautions to be supervised by: _______
4 SNACKS AND MEALS
4.1 A DCP will work with the student and his/her parents/guardians to coordinate a meal and snack schedule in accordance with the attached Health Care Plan that will coincide with the schedule of classmates to the closest extent possible. The student shall each lunch at the same time each day, or earlier if experiencing hypoglycemia. The student shall have enough time to finish lunch. A snack and quick-acting source of glucose must always be immediately available to the student.
4.2 The parents/guardians will pack snacks for each day and will provide a supply of additional snacks to be kept at the school to treat hypoglycemia or for emergency situations.
4.3 All school personnel will permit the student to eat a snack in the classroom or wherever the child is (including, but not limited to classrooms, gym, auditorium, playground, field trips, and school bus) at times designated in the Health Care Plan and whenever needed to treat hypoglycemia or in response to a change in the studentís regular schedule. A source of glucose will be immediately available wherever the student is.
4.4 A designated DCP or DCAP will ensure that the student takes snacks and meals at the specified time(s) each day.
4.5 The attached Health Care Plan sets out the regular time(s) for snacks each day, what constitutes a snack, when the student should have additional snacks, and where snacks are kept.
5 WATER AND BATHROOM ACCESS
5.1 The student shall be permitted to have immediate access to water by keeping a water bottle in the studentís possession and at the studentís desk, and by permitting the student to use the drinking fountain without restriction.
5.2 The student shall be permitted to use the bathroom without restriction.
6. TREATING HIGH OR LOW BLOOD SUGAR
6.1 The student shall have immediate access to blood glucose testing equipment, insulin and syringes, and to glucose in the form of food, juice, glucose gel or tablets in order to treat hypoglycemia. The student shall be permitted to carry this equipment with him/her at all times.
6.2 When any staff member believes the student is showing signs of high or low blood sugar, the staff member will seek a designated DCP for further assistance while making sure an adult stays with the student at all times. Never send a student with actual -- or suspected -- high or low blood sugar anywhere alone.
6.3 High or low blood sugar levels should be treated as set out in the attached Health Care Plan.
6.4 Any staff member who finds the student unconscious will immediately contact the school office. The office will immediately do the following in the order listed:
1. Contact a DCP who will confirm the blood glucose level with a monitor and immediately administer glucagon (glucagon should be administered if no monitor is available);
2. Call 911 (office staff will do this without waiting for the DCP to administer glucagon); and
3. Contact the studentís parent/guardian and physician at the emergency numbers provided below.
6.5 The location of supplies for treating high and low blood sugar levels, including equipment for testing blood glucose levels and ketones, glucagon, and snacks, is set out in the attached Health Care Plan.
7. GLUCOSE TESTS
7.1 Blood glucose tests will be administered in accordance with the level of self-care listed in the chart in section 3 above and the attached Health Care Plan.
7.2 Glucose tests may be done at any location at school, including, but not limited to, the classroom, on school grounds, the cafeteria, at field trips or sites of extracurricular activities, or on the school bus.
7.3 Glucose tests will be done at the times designated in the studentís Health Plan, whenever the student feels that her blood sugar level may be high or low, or when an ACDP or DCAP observes symptoms of hypoglycemia or hyperglycemia.
7.4 The studentís usual symptoms of high and low blood sugar levels are set out in the attached Health Care Plan.
7.5 The location of glucose testing equipment is set out in the attached Health Care Plan.
7.6 A DCP will perform glucose tests when the student is unable or chooses not to do the test himself/herself.
8. INSULIN INJECTIONS
8.1 Insulin will be administered in accordance with the level of self-care listed in the chart in section 3 above and in attached Health Plan.
8.2 The location of insulin and equipment to administer insulin is set out in the attached Health Care Plan.
9. FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES
9.1 The student will be permitted to participate in all field trips and extracurricular activities (such as sports, clubs, and enrichment programs) without restriction and with all of the accommodations and modifications, including necessary supervision by identified school personnel, set out in this Plan. The studentís parent/guardian will not be required to accompany the student on field trips or any other school activity.
9.2 A DCP will accompany the student on all field trips and extracurricular activities outside of the schoolís premises and will provide all usual aspects of diabetes care (including, but not limited to, blood glucose testing, responding to hyperglycemia and hypoglycemia, providing snacks and access to water and the bathroom, and administering insulin and glucagon).
9.3 Either a DCAP or a DCP will be available at the site of all extracurricular activities that take place on school premises. A DCP must be on the school premises whenever the student is present.
9.4 The studentís diabetes supplies will travel with the student to any field trip or extracurricular activity on or off of school premises.
10 TESTS AND CLASSROOM WORK
10.1 If the student is affected by high or low blood glucose levels at the time of regular testing, the student will be permitted to take the test at another time without penalty.
10.2 If the student needs to take breaks to use the water fountain or bathroom, do a blood glucose test, or to treat hypoglycemia or hyperglycemia during a test, the student will be given extra time to finish the test without penalty.
10.3 If the student is affected by high or low blood glucose levels or needs to take breaks to use the water fountain or bathroom, do a blood glucose test, or to treat hypoglycemia or hyperglycemia, the student will be permitted to have extra time to finish classroom work without penalty.
10.4 The student shall be given instruction to help him/her make up any classroom time missed due to diabetes care without penalty.
10.5 The student shall not be penalized for absences required for medical appointments and/or for illness.
11. DAILY INSTRUCTIONS
11.1 A DCP or DCAP will notify parent/guardian ______ days in advance when there will be a change in planned activities such as exercise, playground time, fieldtrips, parties, or lunch schedule, so that the lunch, snack plan, and insulin dosage can be adjusted accordingly.
11.2 The parent/guardian may send the DCP special instructions regarding the snack, snack time, or other aspects of the studentís diabetes care in response to changes in the usual schedule.
11.3 A DCP must provide any substitute teacher with written instructions regarding the studentís diabetes care and a list of all DCPs and DCAPs at the school.
12. EQUAL TREATMENT AND ENCOURAGEMENT
12.1 Encouragement is essential. The student must not be treated in a way that discourages the student from eating snacks on time, or from progressing in doing his/her own glucose tests and general diabetes management.
12.2 The student shall be provided with privacy for blood glucose testing and insulin administration if the student desires.
12.3 DCPs, DCAPs, BDDCPs, and other staff will keep the studentís diabetes confidential, except to the extent that the student decides to openly communicate about it with others.
13. PARENTAL NOTIFICATION
13.1 NOTIFY PARENTS/GUARDIANS IMMEDIATELY IN THE FOLLOWING SITUATIONS:
∑ Symptoms of severe low blood sugar such as continuous crying, extreme tiredness, or loss of consciousness.
∑ The studentís blood glucose test results are below __________ or are below _________15 minutes after consuming juice or glucose tablets.
∑ Symptoms of severe high blood sugar such as frequent urination, presence of ketones or blood glucose level above ______________.
∑ The student refuses to eat or take insulin injection.
∑ Any injury.
13.2 EMERGENCY CONTACT INSTRUCTIONS
1. Call the studentís home. If unable to reach parent/guardian:
2. Call the studentís parent/guardianís cell or work phone. If unable to reach parent/guardian:
3. Repeat same steps with studentís other parent/guardian, if applicable. If unsuccessful:
4. Call the other emergency contacts listed above.
Approved and received:
(Parent sign and date)
Approved and received:
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