SAMPLE

SECTION 504
PLAN

The attached sample Section 504 Plan was developed by the

American Diabetes Association (ADA) and the Disability
Rights Education and Defense Fund, Inc. (DREDF).

MODEL 504 PLAN FOR A STUDENT WITH DIABETES

[NOTE: This model 504 Plan lists a broad range of services and accommodations that might
be needed by a child with diabetes in school. The plan should be individualized to meet the
needs, abilities, and medical condition of each student and should include only those items in the
model that are relevant to that student. Some students will need additional services and
accommodations that have not been included in this model plan.]

Section 504 Plan for ___________________

School ________________________
School Year: _________________
______________________________

________________

Students Name

Birth Date

Homeroom Teacher:

_____

type __ diabetes

Grade

Disability

Bus Number: _________

OBJECTIVES/GOALS OF THIS PLAN

Diabetes can cause blood glucose (sugar) levels to be too high or too low, both of which affect the
students ability to learn as well as seriously endangering the students health both immediately and in the
long term. The goal of this plan is to provide the special education and/or related aids and services
needed to maintain blood glucose within this students target range, and to respond appropriately to levels
outside of this range in accordance with the instructions provided by the students personal health care
team.

REFERENCES
School accommodations, diabetes care, and other services set out by this Plan will be consistent
with the information and protocols contained in the National Diabetes Education Program Helping
the Student with Diabetes Succeed: A Guide for School Personnel, June 2010.

DEFINITIONS USED IN THIS PLAN

1. Diabetes Medical Management Plan (DMMP): A plan that describes the diabetes care regimen and
identifies the health care needs of a student with diabetes. This plan is developed and approved by
the students personal health care team and family. Schools must do outreach to the parents and
childs health care provider if a DMMP is not submitted by the family [Note: School districts may
have other names for the plan. If so, substitute the appropriate terminology throughout.]
2. Quick Reference Emergency Plan: A plan that provides school personnel with essential
information on how to recognize and treat hypoglycemia and hyperglycemia.
3. Trained Diabetes Personnel (TDP): Non-medical school personnel who have been identified by the
school nurse, school administrator, and parent who are willing to be trained in basic diabetes
knowledge and have received training coordinated by the school nurse in diabetes care, including
the performance of blood glucose monitoring, insulin and glucagon administration, recognition and
treatment of hypoglycemia and hyperglycemia, and performance of ketone checks, and who will
perform these diabetes care tasks in the absence of a school nurse.
1. PROVISION OF DIABETES CARE

2.

1.1

At least _______ staff members will receive training to be Trained Diabetes Personnel (TDP),
and either a school nurse or TDP will be available at the site where the student is at all times
during school hours, during extracurricular activities, and on school sponsored field trips to
provide diabetes care in accordance with this Plan and as directed in the DMMP, including
performing or overseeing administration of insulin or other diabetes medications (which, for
pump users includes programming and troubleshooting the students insulin pump), blood
glucose monitoring, ketone checks, and responding to hyperglycemia and hypoglycemia
including administering glucagon.

1.2

Any staff member who is not a TDP and who has primary care for the student at any time
during school hours, extracurricular activities, or during field trips shall receive training that
will include a general overview of diabetes and typical health care needs of a student with
diabetes, recognition of high and low blood glucose levels, and how and when to immediately
contact either a school nurse or a TDP.

1.3

Any bus driver who transports the student must be informed of symptoms of high or low
blood glucose levels and provided with a copy the students Quick Reference Emergency
Plan and be prepared to act in accordance with that Plan.

TRAINED DIABETES PERSONNEL

The following school staff members will be trained to become TDPs by ________________(date):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3. STUDENTS LEVEL OF SELF-CARE AND LOCATION OF SUPPLIES AND

EQUIPMENT
3.1

As stated in the attached DMMP:

(a)The student is able to perform the following diabetes care tasks without help or supervision:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
and the student will be permitted to provide this self-care at any time and in any location at
the school, at field trips, at sites of extracurricular activities, and on school buses.
(b) The student needs assistance or supervision with the following diabetes health care tasks:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

(c) The student needs a school nurse or TDP to perform the following diabetes care tasks:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3.2

The student will be permitted to carry the following diabetes supplies and equipment with
him/her at all times and in all locations:
________________________________________________________________________________
________________________________________________________________________________
3.3

Diabetes supplies and equipment that are not kept on the student and additional supplies and
will be kept at:
________________________________________________________________________________
Parent is responsible for providing diabetes supplies and food to meet the needs of the
student as prescribed in the DMMP.

3.4

4. SNACKS AND MEALS

4.1

The school nurse or TDP, if school nurse is not available, will work with the student and
his/her parents/guardians to coordinate a meal and snack schedule in accordance with the
attached DMMP that will coincide with the schedule of classmates to the closest extent
possible. The student shall eat lunch at the same time each day, or earlier if experiencing
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hypoglycemia. The student shall have enough time to finish lunch. A snack and quick-acting
source of glucose must always be immediately available to the student.
4.2

The attached DMMP sets out the regular time(s) for snacks, what constitutes a snack, and
when the student should have additional snacks. The student will be permitted to eat a snack
no matter where the student is.

4.3

The parent/guardian will supply snacks needed in addition to or instead of any snacks supplied
to all students.

4.4

The parent/guardian will provide carbohydrate content information for snacks and meals
brought from home.

4.5

The school nurse or TDP will ensure that the student takes snacks and meals at the specified
time(s) each day.

4.6

Adjustments to snack and meal times will be permitted in response to changes in schedule
upon request of parent/guardian.

5. EXERCISE AND PHYSICAL ACTIVITY

5.1

The student shall be permitted to participate fully in physical education classes and team sports
except as set out in the students DMMP.

5.2

Physical education instructors and sports coaches must have a copy of the emergency action
plan and be able to recognize and assist with the treatment of low blood glucose levels.

5.3

Responsible school staff members will make sure that the students blood glucose meter, a
quick-acting source of glucose, and water is always available at the site of physical education
class and team sports practices and games.

6. WATER AND BATHROOM ACCESS

6.1

The student shall be permitted to have immediate access to water by keeping a water bottle in
the students possession and at the students desk, and by permitting the student to use the
drinking fountain without restriction.

6.2

The student shall be permitted to use the bathroom without restriction.

7. CHECKING BLOOD GLUCOSE LEVELS, INSULIN AND MEDICATION

ADMININSTRATION, AND TREATING HIGH OR LOW BLOOD GLUCOSE LEVELS
7.1

The students level of self care is set out in section 3 above including which tasks the student
can do by himself/herself and which must be done with the assistance of, or wholly by, either a
school nurse or a TDP.

7.2

Blood glucose monitoring will be done at the times designated in the students DMMP,
whenever the student feels her/his blood glucose level may be high or low, or when symptoms
of high or low blood glucose levels are observed.
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7.3

Insulin and/or other diabetes medication will be administered at the times and through the
means (e.g., syringe, pen or pump) designated in the students DMMP for both scheduled
doses and doses needed to correct for high blood glucose levels.

7.4

The student shall be provided with privacy for blood glucose monitoring and insulin
administration if the student desires.

7.5

The students usual symptoms of high and low blood glucose levels and how to respond to
these levels are set out in the attached DMMP.

7.6

When the student asks for assistance or any staff member believes the student is showing signs
of high or low blood glucose levels, the staff member will immediately seek assistance from
the school nurse or TDP while making sure an adult stays with the student at all times. Never
send a student with actual -- or suspected -- high or low blood glucose levels anywhere alone.

7.7

Any staff member who finds the student unconscious will immediately contact the school
office. The office will immediately do the following in the order listed:

7.8

1.

Contact the school nurse or a TDP (if the school nurse is not on site and
immediately available) who will confirm the blood glucose level with a monitor and
immediately administer glucagon (glucagon should be administered if no monitor is
available);

2.

Call 911 (office staff will do this without waiting for the school nurse or TDP to
administer glucagon); and

3.

Contact the students parent/guardian and physician at the emergency numbers

provided below.

School staff including physical education instructors and coaches will provide a safe location
for the storage of the students insulin pump if the student chooses not to wear it during
physical activity or any other activity.

8. FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES

8.1

The student will be permitted to participate in all school-sponsored field trips and
extracurricular activities (such as sports, clubs, and enrichment programs) without restriction
and with all of the accommodations and modifications, including necessary supervision by
identified school personnel, set out in this Plan. The students parent/guardian will not be
required to accompany the student on field trips or any other school activity.

8.2

The school nurse or TDP will be available on site at all school-sponsored field trips and
extracurricular activities, will provide all usual aspects of diabetes care (including, but not
limited to, blood glucose monitoring, responding to hyperglycemia and hypoglycemia,
providing snacks and access to water and the bathroom, and administering insulin and
glucagon), and will make sure that the students diabetes supplies travel with the student.

9. TESTS AND CLASSROOM WORK

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9.1

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

9.2

If the student needs to take breaks to use the water fountain or bathroom, check blood glucose,
or to treat hypoglycemia or hyperglycemia during a test or other activity, the student will be
given extra time to finish the test or other activity without penalty.

9.3

The student shall be given instruction to help him/her make up any classroom instruction
missed due to diabetes care without penalty.

9.4

The student shall not be penalized for absences required for medical appointments and/or for
illness. The parent will provide documentation from the treating health care professional if
otherwise required by school policy.

10. COMMUNICATION
10.1 The school nurse, TDP, and other staff will keep the students diabetes confidential, except to
the extent that the student decides to openly communicate about it with others.
10.2 Encouragement is essential. The student be treated in a way that encourages the student to eat
snacks on time, and to progress toward self-care with his/her diabetes management skills.
10.3 The teacher, school nurse or TDP will provide reasonable notice to parent/guardian 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.
10.4 Each substitute teacher and substitute school nurse will be provided with written instructions
regarding the students diabetes care and a list of all school nurses and TDP at the school.
11. EMERGENCY EVACUATION AND SHELTER-IN-PLACE
11.1 In the event of emergency evacuation or shelter-in-place situation, the students 504 Plan and
DMMP will remain in full force and effect.

11.2 The school nurse or TDP will provide diabetes care to the student as outlined by this Plan and
the students DMMP, will be responsible for transporting the students diabetes supplies, and
equipment, will attempt to establish contact with the students parents/guardians and provide
updates, and will and receive information from parents/guardians regarding the students
diabetes care.
.

12. PARENTAL NOTIFICATION

12.1 NOTIFY PARENTS/GUARDIANS IMMEDIATELY IN THE FOLLOWING
SITUATIONS:
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Symptoms of severe low blood sugar such as continuous crying, extreme tiredness,
seizure, or loss of consciousness.

The students blood glucose test results are below __________ or are below
_________15 minutes after consuming juice or glucose tablets.

Symptoms of severe high blood sugar such as frequent urination, presence of ketones,
vomiting or blood glucose level above ______________.

The student refuses to eat or take insulin injection or bolus.

Any injury.

Insulin pump malfunctions cannot be remedied.

Other: _________________________________________________________________
______________________________________________________________________________________

12.2 EMERGENCY CONTACT INSTRUCTIONS

Call parent/guardian at numbers listed below. If unable to reach parent/guardian, call the other
emergency contacts or students health care providers listed below.
EMERGENCY CONTACTS:

_________________________

_______________

________________

_______________

Parents/Guardians Name

Home Phone Number

Work Phone Number

Cell Phone Number

_________________________

_______________

________________

_______________

Parents/Guardians Name

Home Phone Number

Work Phone Number

Cell Phone Number

_________________________

_______________

________________

_______________

Name

Home Phone Number

Work Phone Number

Cell Phone Number

_________________________

_______________

________________

_______________

Name

Home Phone Number

Work Phone Number

Cell Phone Number

Other emergency contacts:

Students Health Care Provider(s):

______________________________________

________________

Name

Phone Number

______________________________________

________________

Name

Phone Number
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This Plan shall be reviewed and amended at the beginning of each school year or more often if necessary.
Approved and received:
_______________________________________________
Parent/Guardian

______________________________
Date

Approved and received:

_______________________________________________
School Administrator and Title

______________________________
Date

______________________________________________________-School Nurse

07/24/12
8

_____________________________________
Date