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The Child Advocate is devoted to children and the parents and professionals that work with them and advocate for them.  Diabetes has long been a problem for countless children. This 504 Plan is dedicated to the students with diabetes and parents that seek more independence from the school and have the resources to manage the insulin adjustments with frequent finger sticks and communication by cellular phone.  The specific numbers and guidelines are different for each child.  What is presented here is for example only and is not a recommendation.  Additional 504 information is at the ADA site.  The information presented at this site is for general use only and is not intended to provide personal advice or substitute for the advice of a qualified professional.  If you have questions about the information presented here, please consult a physician skilled in diabetes management, the resources listed or other professional in your area.




2001 – 2002 SCHOOL YEAR


NAME:     SUE SMITH                                   BIRTH DATE:   5/30/xx           GRADE:     4

ADDRESS:   850 Our Drive, Hometown, PA 17110

SCHOOL: Intermediate Elementary                 HOMEROOM TEACHER:   Miss Jones

BUS NUMBER:       4                                     DISABILITY:        Diabetes Type 1


  1. Describe the nature of the concern:  

Sue has type 1 diabetes. Diabetes is a serious, chronic disease that impairs the body’s 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 doesn’t make insulin or the body cannot use insulin properly. Without insulin, the body’s main energy source – glucose – 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 student’s 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.


  1. Describe the basis for the determination of handicap (if any):

See attached reports from Dr. Leslie Jones, dated December 2000. 


  1. Describe how the handicap affects a major life activity:

Both high blood sugar levels and low blood sugar levels affect Sue’s ability to learn, as well as seriously endangering her health.   Blood glucose levels must be maintained in the prescribed range for optimal learning and testing of academic skills.   Sue has a recognized disability, type 1 diabetes, that requires the accommodations and modifications set out in this Plan to ensure that Sue has the same opportunities and conditions for learning and academic testing as classmates, with minimal disruption of Sue’s regular school schedule and with minimal time away from the classroom.



  1. Describe the reasonable accommodations that are necessary:




  • 1 A school nurse is on staff during school hours for consultation concerning Sue’s health care in accordance with this Section 504 Plan.
  • 2 The school nurse or school administrators may converse with and obtain information from the physician concerning Sue whenever the school believes it would be helpful to do so.

1.3    School staff (Sue’s teachers, recess aides, gym teachers, librarians, bus drivers, etc.) will be instructed and provided with literature on diabetes, including symptoms of hypoglycemia and symptoms of hyperglycemia.

1.4    With regard to students with diabetes and all students, the highest priority of YOUR SCHOOL DISTRICT is to maintain the health and safety of the student. The District also seeks to enhance the student’s independence whenever this is consistent with health and safety. Any changes that are inconsistent with this Section 504 Plan will be recorded in a new Section 504 Plan, and should be based on a sharing of experience and information among Sue, her parents, her physician, and school officials. The initiation of action under this Section 504 Plan is dependent on the signed completion, by Sue’s parents and by her physician.

  • During the first week of the operation of this Section 504 Plan, the nurse assistant will join Sue in her classroom in order to monitor Sue’s blood glucose testing throughout the day. Sue’s mother may choose to come to the classroom prior to the 11:10 a.m. testing or at other times at her discretion. During this one-week period, Sue will not test her blood glucose level except in the presence of the nurse assistant.
  • If, at the end of the one-week period, the nurse assistant believes it is not appropriate for Sue to test her blood glucose level by herself, the District will notify Sue’s parents and an additional two-week trial period will be initiated. In such case, Sue will continue to test her blood glucose level only in the presence of the nurse assistant.
  • If, at the end of the one-week period, the District does not notify Sue’s parents that Sue’s independent testing is counter-indicated, Sue will be permitted to test her blood glucose level without the monitoring of the nurse assistant.
  • At any time in which school staff observe symptoms of hyperglycemia or hypoglycemia that reasonably indicate that Sue may not be able to effectively test her own blood glucose level independently, the school staff have the option of requiring that Sue’s blood glucose level be tested with the assistance of the nurse assistant at a location to be chosen by the school staff.

1.5    The presence of other antibodies (HIV, Hepatitis C, Syphilis, or any other blood borne diseases) will be cause for review of the 504 Plan and probable return to the nurse’s office for diabetic monitoring.

1.6    Sue will notify the staff of any blood spills for immediate cleanup by appropriate personnel under YOUR SCHOOL DISTRICT‘s Educational Policy – Prevention of Disease Transmission in Schools.  

1.7    Use of retractable lancets is mandatory in the blood glucose testing while on school property or during school sanctioned activities. Sue will return the retractable lancets to her test kit and dispose of them at home.



As per Dr. Jones’s signature on this Plan, Sue tests her blood glucose level and manages her care via the insulin pump independently as indicated by the following.

Totally independent management (only requires adult assistance during severe hypoglycemia and hyperglycemia).

  • Sue tests blood glucose level independently.
  • Sue administers insulin independently via insulin pump.
  • Sue self-treats mild hyperglycemia and mild hypoglycemia.
  • Sue monitors own snacks and meals.
  • Sue tests and interprets own urine ketones.
  • Sue implements universal precautions.


    • 1 Blood glucose testing will be routinely done in an area of Sue’s classroom that is designated by the teacher, in accordance with the level of self-care listed in Section 2. Additionally, blood glucose testing may be done on an as needed basis or in the event of hypoglycemia or hyperglycemia in other locations such as, on school grounds, the cafeteria, at field trips or sites of extracurricular activities, or on the school bus.
    • 2 The parents will provide a cell phone to be kept in a closed backpack at all times and used only for the purpose of communicating with Sue in her diabetes management.
    • 3 Sue shall be permitted to carry blood glucose monitor, snacks, glucose tablets, cake mate, ketostix and cell phone with her in a closed backpack at all times. She will have immediate access to blood glucose testing equipment and to glucose in the form of food or juice in order to treat hypoglycemia.
    • 4 Glucose tests will be done at 11:10 a.m. or whenever she feels that her blood sugar level may be high or low, or when school staff or nurse observes symptoms of hypoglycemia or hyperglycemia.
    • 5 Sue’s target range for blood glucose is 70 – 180.
    • 6 The school nurse will be notified if Sue:
  • Is unable to test herself.
  • Exhibits severe signs of hyperglycemia.
  • Exhibits severe signs of hypoglycemia.


3.7    Parents will provide backup supplies necessary for her insulin pump and blood glucose monitoring to be kept in nurse’s office.


    • 1 Sue is currently using a Minimed 507C.
    • 2 Sue will administer insulin, independently, with the level of self-care listed in Section 2.
    • 3 Her current insulin/carbohydrate ratio is 0.4/15.
    • 4 Her correction factor is 0.8 units per 100 points.
    • 5 Her ratio and correction factor change frequently and should be confirmed by Sue, her parents or doctor.     Questions regarding insulin pumps and functioning can be answered by Minimed at 1-800-826-2099.



5.1    Symptoms of Hypoglycemia (Low Blood Sugar) include:

  • Extreme hunger
  • Personality change
  • Weakness
  • Exhaustion: “Feel like I’m going to splat on the floor.”
  • Sleepiness/tiredness/fatigue
  • Shakiness/trembling
  • Inability to concentrate
  • Pale appearance
  • Flushed face
  • Headache

5.2    Symptoms of Hyperglycemia (High Blood Sugar) include:

  • Increased thirst
  • Increased urination
  • Inability to concentrate
  • Giddiness, wound up
  • Increased hunger
  • Blurred vision
  • Fatigue/sleepiness
  • Stomach pain
  • Headache


    • 1 When any staff member believes Sue is showing signs of high or low blood sugar, the staff member will notify the school nurse for further assistance while making sure an adult stays with Sue at all times.
  • Never send Sue with actual—or suspected—high or low blood sugar anywhere without an adult.


  • 2 Treatment of hypoglycemia:
  • Juice box or 15 grams of fast acting sugar.
  • Sue will notify adult in charge, if number’s below 60. Adult will notify nurse.
  • Rest in nurse’s office as needed.
  • Telephone parents as needed.

6.3    If Sue is unconscious, convulsing or unable to swallow:

  • Staff should administer cake mate from backpack if conscious, but unable to swallow. Cake mate to be placed between lower lip and gums to avoid choking until nurse arrives;
  • The nurse shall administer glucagon promptly;
  • Call 911; and
  • Contact Sue’s parent and physician at the emergency numbers provided in Plan.


6.4   Treatment of hyperglycemia:

  • Drink plenty of water.
  • Administer a bolus of insulin.
  • Urine ketones should be tested when blood sugar is 300 and above.
  • Telephone parents as needed.
  • Schedule followed by Sue and parents; if over 180, call Mom to adjust insulin.





  • 1 Sue’s daily food intake:
  • Lunch 12:15
  • Snack before and after exercise as needed
  • For treatment of hypoglycemia as needed


  • 2 Blood glucose ranges and treatment for each as per Sue’s discretion or:
  • If 70 to 180 (medium), take no carbs;
  • If below 60 to 70 (low), take one (1) carb (15 grams carbohydrates);
  • If below 60 (very low), take one (1) carb (15 grams carbohydrates) and notify staff member who will notify nurse;
  • If less than 50, take one and a half (1 ½) carbs.


  • 3 The parents will provide a supply of additional snacks to be kept at the school for treatment of hypoglycemia, and provide snacks in her backpack daily.


  • 4 All school personnel will permit Sue to eat a snack in the classroom or wherever she is (including, but not limited to, classrooms, gym, auditorium, playground, field trips and school bus).


  • 5 Sue shall eat lunch at the same time daily, or earlier, if experiencing hypoglycemia. Sue shall have enough time to finish lunch.


  • 6 A snack or quick-acting source of glucose must always be immediately available to Sue, which she carries in her backpack.

7.7    Guidelines when food is provided to the class, e.g., as part of a class party or food sampling:

  • If Sue is unable to determine her bolus for the snack, Sue will call mother or father to confer.



8.1    Sue shall be permitted to have immediate access to drinking water without restriction.

8.2    Sue shall be permitted use of the restroom without restriction.




9.1    Sue 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. Sue’s parents will not be required to accompany Sue on field trips or any other school activity.


9.2    A staff member educated in diabetes or a school nurse will accompany Sue on all field trips and extracurricular activities outside of the school’s premises responding, but not limited to, hyperglycemia and hypoglycemia, providing snacks, access to water, the restroom and including administering of glucagons, unless other arrangements are mutually agreed upon in advance.


9.3    Sue’s diabetic supplies will travel with Sue to any field trip or extracurricular activity on or off of school premises.





10.1  If Sue is affected by high or low blood glucose levels at the time of regular testing, she will be permitted to take the test at another time without penalty.


10.2  If Sue needs to take breaks to use the water fountain or restroom, do a blood glucose test, or to treat hypoglycemia or hyperglycemia during a test, she will be given extra time to finish the test without penalty.


10.3  If Sue is affected by high or low blood glucose levels or needs to take breaks to use the water fountain or restroom, do a blood glucose test, or to treat hypoglycemia or hyperglycemia, she will be permitted to have extra time to finish classroom work without penalty.


10.4  Sue shall be given instruction to help her make up any classroom time missed due to diabetic care without penalty.


10.5  Sue shall not be penalized for absences required for medical appointments and/or for illness.





11.1  A school staff member will notify parent at least one (1) day in advance when there will be a change in planned activities such as exercise, playground time, field trips, parties, or lunch schedule, so that the lunch, snack plan, and insulin dosage can be adjusted accordingly.


11.2  The parent may send the school staff special instructions regarding the snack, snack time, or other aspects of Sue’s diabetes care in response to changes in the usual schedule.


11.3  The classroom teacher must provide any substitute teacher with written instructions regarding Sue’s diabetes care, nurse’s direct line, and access to the 504 Plan.





  • 1 Encouragement is essential. Sue must not be treated in a way that discourages her from eating snacks on time, or from progressing in doing her own glucose tests, bolusing and general diabetes management.


  • 2 Sue shall be provided with privacy for blood glucose testing and insulin administration, if she desires.





  • Symptoms of severe low blood sugar such as continuous crying, extreme tiredness, or loss of consciousness.
  • Sue’s blood glucose level falls below 60.
  • Symptoms of severe high blood sugar such as frequent urination, presence of ketones or blood glucose level above 200.
  • Sue refuses to eat or administer the needed bolus.
  • Any injury.




  1. Call Mom’s cell phone number, home phone number or beeper.
  2. If unable to communicate with Mom, contact Dad’s pager.
  3. If unable to contact Dad, call other emergency contact.




Parent’s Name                       Home Phone Number       Work Phone Number        Cell Phone Number


Parent’s Name                       Home Phone Number       Work Phone Number        Cell Phone Number




Other Emergency Contacts:


Name                                    Home Phone Number       Work Phone Number        Cell Phone Number



Name                                    Home Phone Number       Work Phone Number        Cell Phone Number



Doctor                                                                          Phone Number




Pump, Trainer & Counselor                                           Phone Number

This Plan shall be reviewed and amended at the beginning of each school year or more often if necessary.


Approved and received:                                                                    Date







School Representative/Title





We understand that classroom teachers have no obligations under this Plan other than to take reasonable care to ensure that Sue has prompt access to the school nurse when Sue indicates a desire or need for such access.


We agree that Sue is responsible for any consequences of her monitoring, testing, test-interpretive, or self-treatment decisions.








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