ࡱ> svr[ 4-bjbjmm 46bbNNNbbb8L<btV"8888sssssss$vy t9N" t88dEtR88N8vrpsn?6B80R<^@ br[t0t@-zn-z@B-zNB/ t t0t-zB :  SAMPLE EMERGENCY CARE PLAN OF HYPERGLYCEMIA Student: __________________________ Grade: _____ School: ________________________ DOB:_______ Parent/Guardian Name _________________________ Phone #:_______________________ ( Check if cell Parent/Guardian Name _________________________ Phone #:_______________________ ( Check if cell Emergency Contact if Parent/Guardian cannot be reached: ________________________________________ Relationship:____________________________ Phone:______________________________ ( Check if cell Parent /Guardian Signature: _______________________________________________ Date: ___________ This plan will be reviewed with appropriate school staff on a need to know basis to maintain student safety  SYMPTOMS OF A HYPERGLYCEMIC EPISODE MAY INCLUDE ANY/ALL OF THESE: Extreme thirst, frequent urination, increased hunger, fatigue Lack of concentration, sweet fruity breath, blurred vision Dry mouth, nausea, stomach pain, vomiting SEVERE SYMPTOMS INCLUDE: Labored breathing, very weak, confusion, unconsciousness STAFF MEMBERS INSTRUCTED: ( Classroom Teacher(s) ( Special Area Teacher(s) ( Administration ( Support Staff ( Transportation TREATMENT: Stop any activity immediately. Accompany the student to the Health Office. Notify school nurse immediately. CHECK BLOOD GLUCOSE LEVEL: If blood glucose > __________mg/dl Unresponsive% Send student to school nurse with escort % Encourage student to drink water or sugar free drink. % Check urine for ketones % Restrict participation in physical activity if ketones are moderate to large, or blood ketones are >0.6 mg/dl. % Recover position to maintain safety. % Notify Parent/Guardian % Call 911 or EMS per school policy % Stay with student until help arrives. Healthcare Provider: ____________________________________ Phone: _____________________________ Written by: ______________________  %-./07DSy˼weWI;+I;hR ho5>*OJQJ^JhR h@%5OJQJ^JhR ho5OJQJ^JhW#Jho5OJQJ^J#h@%h'5CJOJQJ^JaJ#h@%hg4h5CJOJQJ^JaJh5CJOJQJ^JaJ#h@%h#yB5CJOJQJ^JaJ#h@%ho5CJOJQJ^JaJhk5CJOJQJ^JaJ#h@%h@%5CJOJQJ^JaJ#h@%h^5CJOJQJ^JaJ hrgHh3~5B*CJaJph/0] & (($IfgdR dh(($IfgdR $ a$gdK gd@%  * J K L ] ^ ĶҡĶĶzhVFhR h3n 5>*OJQJ^J#hR h@%5CJOJQJ^JaJ#hR h@%5CJOJQJ^JaJ) jchR h@%5CJOJQJ^JaJ#hR ho5CJOJQJ^JaJ) jchR ho5CJOJQJ^JaJhR h3n 5OJQJ^JhR h@%5OJQJ^JhR ho5OJQJ^JhR h@%5>*OJQJ^JhR ho5>*OJQJ^J         % & ' Ͽ߱߱ϿϿϿ߱ߊxj]PhR h@%OJQJ^JhR h3n OJQJ^JhR h3n 5OJQJ^J#hR h@%5CJOJQJ^JaJ#hR ho5CJOJQJ^JaJ) jchR ho5CJOJQJ^JaJhR h@%5OJQJ^JhR h@%5>*OJQJ^JhR ho5>*OJQJ^JhR ho5OJQJ^J#hR h@%5CJOJQJ^JaJ   8 9 J R S V ] p v w ϵxndnZdnZLnZ>nhmuhF5OJQJ^Jh.#Vh.#V5OJQJ^Jh yOJQJ^Jh:OJQJ^Jh,OJQJ^JhW#Jh6Z5>*OJQJ^JhW#Jh/5>*OJQJ^Jh5>*OJQJ^JhW#JhS{p5>*OJQJ^J2jhW#JhY5>*OJQJU^JmHnHu#hd{h5CJOJQJ^JaJhR ho5OJQJ^J hR hoCJOJQJ^JaJ 9 w / 0 L {{vnidgdgdB & F gd,gd6Z & F gd: & F gd.#VgdFnkd$$Ifl** t0644 lalp ytR   . / 0 I K L M e f  ˻˰wi^NDN7DNhW#JhOJQJ^Jh@%OJQJ^J jqhW#JhOJQJ^Jh@%5OJQJ^JhW#Jh5OJQJ^JhW#Jh5>*OJQJ^J hd{hCJOJQJ^JaJh,hFOJQJ^Jh,5OJQJ^Jhmu5OJQJ^JhW#JhF5>*OJQJ^JhW#Jh6Z5>*OJQJ^JhW#JhOJQJ^Jh:hmu5OJQJ^JhmuOJQJ^J 2 3 L M N O ` ϾwgWF9h&h1OJQJ^J hohoCJOJQJ^JaJh*Tjh9)5>*OJQJ^Jh*Tjh3n 5>*OJQJ^Jh*Tjh*Tj5>*OJQJ^Jh*TjOJQJ^JhW#Jh#OJQJ^JhW#Jhi5>*OJQJ^JhW#Jh#5>*OJQJ^J hd{h@%CJOJQJ^JaJhOJQJ^JhW#JhOJQJ^J jqhW#JhOJQJ^Jh@%OJQJ^JL 2 3 N O r s $$Ifa$gd& $Ifgd1gdo & F gd@%]gd@%gd ` a r s  TV*,.\^~,ל͒͜䈜͜~p`RpPUhR hd{5OJQJ^JhR h95>*OJQJ^JhR h95OJQJ^Jh9OJQJ^Jh1OJQJ^Jhc7OJQJ^Jh&hm$OJQJ^Jh,OJQJ^Jh&h,OJQJ^Jh&h,OJQJ^Jhm$OJQJ^Jh&h1OJQJ^Jh&h1OJQJ^Jh&h1>*OJQJ^J V,^xof]]offff $Ifgdm$ $Ifgd1 $Ifgd,kd$$Ifl0* t0644 lahpyt& ?,@,xofff $Ifgd9h^hgd9kd&$$Ifl0* t0644 lahpyt&______________________ Date: ______________________________  ( Copy provided to Parent ( Copy sent to Healthcare Provider Sample NYSCSH Resource located at  HYPERLINK "http://www.schoolhealthny.com" www.schoolhealthny.com -Sample Forms Notification 10/17     Student Photo ,,?,A,B,C,\,h,i,j,,,,,,,,,,,ó{j{jTjTA%hR h^0JB*OJQJ^Jph*jhR h^B*OJQJU^Jph!hR h^B*OJQJ^Jph!hR h3n B*OJQJ^Jphh3n h3~OJQJ^JhW#JhiOJQJ^JhW#JhOJQJ^J jqhW#JhOJQJ^J h9h3~CJOJQJ^JaJhR h9OJQJ^JhR h95>*OJQJ^JhR h95OJQJ^J@,A,B,,-------- -xsqsqsqsqgdyg$a$gd3~ $dha$gd3n gd9nkd$$Ifl*+ t0644 lap ytR ,,,,, ----------- -!-"-#-1-2-3-4-ƸקhS{phFh=lhh'6CJ$aJ$hbjhbU!hR h1B*OJQJ^JphhrB*OJQJ^Jph!hR h3n B*OJQJ^Jph!hR h^B*OJQJ^Jph.jhR h^0JB*OJQJU^Jph -!-"-#-+-1-2-3-4-$a$gd3~$a$gdF$a$gd21F:p3n / =!"#$% $$Ifl!vh#v*:V l t065*alp ytR $$Ifh!vh#v#v:V l t0655ahpyt&$$Ifh!vh#v#v:V l t0655ahpyt&$$If!vh#v+:V l t065+p ytR s2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4@4 Header  !4 4 Footer  !HH i Balloon TextCJOJQJ^JaJ6U`!6 ^ Hyperlink >*B*phj3j o Table Grid7:V0PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< 6  ` ,,4-  L @, -4- /[rX@ @H 0(  `(  (b %0Q-T  #" ?4  %0Q-Tz  3 C"?&+ B S  ?f!#* topIJRS]^op .OrsopIJRS]^op .Orsop b%kZ!Z*1 jvWU!jnU 'H)x>.յ:Ѹ< N$y_N6o`weI}Zl+M~`s3 n}Vf~\{ ^`hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. 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