Action and Management Plans 2024

You can submit your request for 2024. School plan requests will be completed in order of the date received and will take at least 4-6 weeks to process.

This form is for RCH patients only.

Only use this form if you have been unable to complete the appropriate PDF Action / Management Plan template below.  

2024 PDF Diabetes School Action and Management plans: 

• Multiple daily injections (requiring lunch time insulin injection) 
• Insulin pump therapy for automated insulin Hybrid Closed Loop (Control IQ® Tandem T-Slim x2, SmartGuard® Medtronic and CamAPS® FX Ypso) 
• Insulin pump therapy, manual mode only, not using a hybrid closed loop system
• Type 2 diabetes, having insulin
• Type 2 diabetes, on oral medication (no insulin injections) 

Please note the above plans require a computer as they cannot be completed via a mobile phone or tablet. If you do not have access to a personal computer your child's school or the local library will have computers for you to use

Once you have completed this form, you will need to send it via email to diabetes@rch.org.au. If you complete the pdf above you should expect to receive the plan earlier

In the meantime your 2023 plan can be used by your child's school

Details

If a box is left blank we will fill it in as per RCH guidelines.

 

First name

Last name

Date of birth

Year Level (2024)

Child care Kindergarten Prep Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12

 

Type of diabetes: 

1. Type 1 diabetes
2. Type 2 diabetes
3. Cystic fibrosis related diabetes
4. Steroid induced diabetes
5. Monogenic diabetes
6. Other - please fill in below

 

 

Name of school

RCH hospital UR number

Parent/carer name

Parent/carer email address (to email plan to) 

Do you give permission for us to email the plan to the above email provided?

1. Yes
2. No

Parent/carer contact number

How many times per day does your child have insulin?

1. Before breakfast, lunch, dinner and long acting insulin (4 x per day)
2. Before breakfast and dinner (2 x per day)
3. Insulin pump

What insulin(s) does your child currently use?

1. NovoRapid
2. Levemir
3. Optisulin/glargine
4. NovoMix 30
5. Humalog
6. Ryzodeg
7. Humalog Mix 25
8. Fiasp
9. Actrapid

Does your child require an insulin injection at school?

1. Yes
2. No

Indicate if your child requires assistance to give the injection, supervision, or are independent with insulin injection or their pump bolus at school? 

Notes: A Medication Authority Form (MAF) is required for children who need supervision or assistance. All primary school aged children require supervision with giving insulin. 

1. Independent with giving insulin
2. Supervision required (child administers but staff member supervises) - Medication Authority Form required.
3. Requires trained staff member to give insulin. Medication Authority Form required.

 

Names of responsible staff who have voluntarily agreed to undertake training and provide diabetes support at school.

Indicate if they are trained to check BGLs and if they can administer insulin 

Blood glucose monitoring and sensor glucose monitoring - continuous glucose monitoring (CGM) or flash glucose monitoring (FlashGM)

Is your child able to check their own blood glucose levels? 

1. Yes they can check their own BGLs
2. No support is required for checking BGLs

The responsible staff members need to support BGL checking at school: 

1. Do the check
2. Assist with the check
3. Observe the check
4. Remind to check

 

Times to check the BGL (fingerprick) at school: 

1. Anytime a hypo is suspected
2. Before activity
3. Before snack
4. Before lunch
5. Beginning of after school session
6. When feeling unwell

 

Are there other times a BGL is needed? 

CGM or FlashGM 

Is your child wearing a CGM or FlashGM?

1. Dexcom
2. Libre
3. Medtronic Guardian Connect
4. Medtronic Guardian Link to pump

 

Hypoglycaemia (low blood glucose levels) 

What fasting acting carbohydrate does your child use if their blood glucose is below 4 mmol/L at school? e.g. specify 2 X glucose tablets 

What long acting hypo food does your child use at school? How much long acting carbohydrate does your child use at school? e.g. 1 x muesli bar or 1 x piece of fruit 

Where at the school are the hypo supplied kept? 

Hyperglycaemia management (high blood glucose levels) 

Although not ideal, BGLs above target range are common. IF a BGL is 15.0 mmol/L or higher, the school follow the Diabetes Acton Plan. 

Ketones: 

Does your child have access to ketone checking at school? 

Note: Children using insulin pumps must have access to blood ketone schecking at school 

1. Yes using blood ketones
2. Urine ketone strips
3. no ketone monitoring at school

Food

For children having insulin injections at lunch time, 

The insulin dose is determined at lunch time by: 

1. A set dose of insulin (parent/carer to determine the dose at the start of the day/week)
2. Flexible dosing using a dosing card
3. Flexible dosing using an app MyLife
4. Flexible dosing using the Libre bolus calculator reader

Especially for Early Learning and Primary school aged children, all carbohydrates should be clearly labeled by the parent/carer. 

Will carbohydrates be labeled and counted in:

1. Serves of carbohydrate
2. grams of carbohydrates

Does your child have a diagnosis of coeliac disease? 

1. Yes
2. No

 

Sport at school 

Does your child have activity carbohydrate based on what their BGL is before sport? 

1. Yes
2. No

 If yes, indicate when they will and will not have a snack before sport? e.g. BGL 10 mmol/L or higher and doing low intensity sport no snack is required 

 

Equipment Checklist

Diabetes equipment that comes to school daily: 

1. Insulin pens and pen needles (or syringes and insulin)
2. Finger prick device
3. Blood glucose monitor used by student at school and at home
4. Blood glucose strips
5. Blood ketone strips
6. Urine ketone strips
7. Hypo food
8. Activity food

 

BACKUP Equipment to stay at school: 

1. Insulin pens and pen needles (or syringes and insulin). Stored according to the school’s Medication Policy.
2. Finger prick device
3. Blood glucose monitor
4. Spare batteries for blood glucose monitor
5. Charging cable for glucose monitoring devices (if required)
6. Blood glucose strips
7. Blood ketone strips
8. Urine ketone strips
9. Sharps container
10. Hypo food
11. Activity food

 

BACKUP equipment for insulin pumps: 

1. Insulin pens and pen needles (or insulin and syringes)
2. Infusion sets and lines
3. Reservoirs
4. Cartridges
5. Inserter

 

Insulin pumps:  

Does your child use an insulin pump?

1. Yes
2. No

Which model of pump does your child use?

1. Tandem T Slim
2. Medtronic 640G
3. Medtronic 670G
4. Medtronic 770G
5. Medtronic 780G
6. Ypso

Able to independently count carbohydrate foods?

1. Yes
2. No

Able to enter a BGL and carbohydrate grams into the pump?

1. Yes
2. No

Able to do a correction bolus?

1. Yes
2. No

Able to disconnect and reconnect pump if needed?

1. Yes
2. No

Restart pump manually?

1. Yes
2. No

Able to prepare and insert a new infusion set if needed?

1. Yes
2. No

Give an insulin injection if needed?

1. Yes
2. No

Able to troubleshoot pump alarms and malfunctions?

1. Yes
2. No

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