Neenah  Joint  School  District  410  S  Commercial  St.  Neenah,  WI  54956  

 Diabetic  Emergency  Plan  

 Section  1:  Procedure        If  a  known  diabetic  student  is  having  a  seizure  or  becomes  unresponsive  i.e.  unable  to  talk,  walk,  or                  respond  to  questioning  and  is  unable  or  unwilling  to  swallow  oral  sugar  products:  

 1. Trained  staff  member  administers  glucagon,  if  available.  2. Dial  911  for  an  ambulance  to  transport  student  to  hospital  3. Notify  parent  or  emergency  contact  

   

Section  2:  Medication    GLUCAGON:  Inject  IM  thigh                      !      Glucagon  1mg     !      Glucagon  0.5  mg    Possible  side  effects:    ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  

                                                                                                                                 

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Student  ______________________________________________________________  Date  ________________________  Grade____________________    Date  of  Birth  __________________School  __________________________________Teacher  ____________________________________________    Address_________________________________________________  Parent/Guardian___________________________________________________    City  __________________________________  Zip  Code_________________________  Home  Phone_______________________________________    Emergency  Contacts:    Name_____________________________________________  Number_____________________________  Relationship________________________    Name_____________________________________________  Number_____________________________  Relationship________________________    Name_____________________________________________  Number_____________________________  Relationship________________________      

 

Physician  Information  Print  Name  of  Provider___________________________________________________________  Clinic  Name  ________________________  Phone  Number______________________________________________________  Fax  Number  ______________________________________  Address  __________________________________________________________________________________________________________________    Signature  of  Provider_____________________________________________________________________  Date_________________________  

Parent  consent  for  management  of  health  condition  while  at  school  or  other  school  related  activities    I,  the  parent/guardian  of  the  above  named  student,  request  that  this  action  plan  be  used  to  guide  the  care  of  my  child  in  case  of  a  health  care  emergency.    I  agree  to:    

1. Provide  the  necessary  supplies  and  equipment.  2. Notify  the  school  staff  or  school  district  nurse  of  any  changes  in  the  student’s  health  status.  3. Notify  the  school  staff  and  complete  new  consent  for  changes  in  orders  from  the  student’s  health  care  

provider.  4. Authorize  the  school  nurse  to  communicate  with  my  child’s  primary  care  physician  or  specialist  

regarding  my  child’s  health  condition  as  needed.  5. School  staff  interacting  directly  with  my  child  may  be  informed  about  this  health  care  plan.  6. Submit  new  forms  annually  if  the  health  condition  still  exists  or  inform  the  school  that  the  condition  

no  longer  exists.    Parent/Guardian  Signature__________________________________________________  Date__________________________