Diabetes at the RCH : Diabetes school plan

Action and Management Plans 2025

You can submit your request for 2025. 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.

2025 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.

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 2024 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 (2025)

Type of diabetes:

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?

Yes
No

Parent/carer contact number

How many times per day does your child have insulin?

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

What insulin(s) does your child currently use?

Does your child require an insulin injection at school?

Yes
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.

Independent with giving insulin
Supervision required (child administers but staff member supervises) - Medication Authority Form required.
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?

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

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

Do the check
Assist with the check
Observe the check
Remind to check

Times to check the BGL (fingerprick) at school:

Are there other times a BGL is needed?

CGM or FlashGM

Is your child wearing a CGM or FlashGM?

Dexcom
Libre
Medtronic Guardian Connect
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

Yes using blood ketones
Urine ketone strips
no ketone monitoring at school

Food

For children having insulin injections at lunch time,

The insulin dose is determined at lunch time by:

A set dose of insulin (parent/carer to determine the dose at the start of the day/week)
Flexible dosing using a dosing card
Flexible dosing using an app MyLife
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:

Serves of carbohydrate
grams of carbohydrates

Does your child have a diagnosis of coeliac disease?

Yes
No

Sport at school

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

Yes
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:

BACKUP Equipment to stay at school:

BACKUP equipment for insulin pumps:

Insulin pumps:

Does your child use an insulin pump?

Yes
No

Which model of pump does your child use?

Able to independently count carbohydrate foods?

Yes
No

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

Yes
No

Able to do a correction bolus?

Yes
No

Able to disconnect and reconnect pump if needed?

Yes
No

Restart pump manually?

Yes
No

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

Yes
No

Give an insulin injection if needed?

Yes
No

Able to troubleshoot pump alarms and malfunctions?

Yes
No

The Royal Children's Hospital Melbourne