Diabetes Medical
Management Plan (DMMP)

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This plan should be completed by the student’s personal diabetes health care team, including the parents/guardians. It should be reviewed with relevant school staff and copies should be kept in a place that can be accessed easily by the school nurse, trained diabetes personnel, and other authorized personnel.

Date of plan:  	

This plan is valid for the current school year:  	– 	

Student information

Student’s name:  	

Date of birth:  	

Date of diabetes diagnosis:  	

Type 1	Type 2	Other:  	

School:  	

School phone number:  	

Grade:  	

Homeroom teacher:  	

School nurse:  	

Phone:  	

Contact information

Parent/guardian 1:    	
Address:   	

Telephone:  Home:  	

Work:   	

Cell:   	

Email address:   	

Parent/guardian 2:  	
Address:   	

Telephone:  Home:  	

Work:   	

Cell:   	

Email address:   	

Student’s physician/health care provider:  	
Address:   	

Telephone:  	

Emergency number:  	

Email address:  	
Other emergency contacts:

Name:  	

Relationship:  	

Telephone:  Home:  	

Work:   	

Cell:   	

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Checking blood glucose

Brand/model of blood glucose meter:  	 Target range of blood glucose:
Before meals:	90–130 mg/dL	Other:  	
Check blood glucose level:
Before breakfast	After breakfast	 	Hours after breakfast	2 hours after a correction dose
Before lunch	After lunch	 	Hours after lunch	Before dismissal
Mid-morning	Before PE	After PE	Other:   	
As needed for signs/symptoms of low or high blood glucose	As needed for signs/symptoms of illness
Preferred site of testing:	Side of fingertip	Other:  	
Note: The side of the fingertip should always be used to check blood glucose level if hypoglycemia is suspected.
Student’s self-care blood glucose checking skills:
Independently checks own blood glucose
May check blood glucose with supervision
Requires a school nurse or trained diabetes personnel to check blood glucose
Uses a smartphone or other monitoring technology to track blood glucose values
Continuous glucose monitor (CGM):	Yes	No   Brand/model:  	

Alarms set for:	Severe Low:  	

Low:  	

High:  	

Predictive alarm:  Low:  	

High:  	

Rate of change:  Low:  	

High:  	

Threshold suspend setting:  	

Additional information for student with CGM
• Confirm CGM results with a blood glucose meter check before taking action on the sensor blood glucose level.
If the student has signs or symptoms of hypoglycemia, check fingertip blood glucose level regardless of the CGM.
• Insulin injections should be given at least three inches away from the CGM insertion site.
• Do not disconnect from the CGM for sports activities.
• If the adhesive is peeling, reinforce it with approved medical tape.
• If the CGM becomes dislodged, return everything to the parents/guardians. Do not throw any part away.
• Refer to the manufacturer’s instructions on how to use the student’s device.

Student’s Self-care CGM Skills	Independent?	
The student troubleshoots alarms and malfunctions.	Yes	No	
The student knows what to do and is able to deal with a HIGH alarm.	Yes	No	
The student knows what to do and is able to deal with a LOW alarm.	Yes	No	
The student can calibrate the CGM.	Yes	No	
The student knows what to do when the CGM indicates a rapid trending rise or fall in the blood glucose level.	
Yes	
No	

The student should be escorted to the nurse if the CGM alarm goes off:	Yes	No
Other instructions for the school health team:  	

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Hypoglycemia treatment

Student’s usual symptoms of hypoglycemia (list below):  	

If exhibiting symptoms of hypoglycemia, OR if blood glucose level is less than  	mg/dL, give a quick-acting glucose product equal to  	grams of carbohydrate.
Recheck blood glucose in 15 minutes and repeat treatment if blood glucose level is less than  	mg/dL.
Additional treatment:  	

If the student is unable to eat or drink, is unconscious or unresponsive, or is having seizure activity or convulsions
( jerking movement):
• Position the student on his or her side to prevent choking.
• Give glucagon:	1 mg	½ mg	Other (dose)  	
• Route:	Subcutaneous (SC)	Intramuscular (IM)
•  Site for glucagon injection:	Buttocks	Arm	Thigh	Other:  	
• Call 911 (Emergency Medical Services) and the student’s parents/guardians.
• Contact the student’s health care provider.

Hyperglycemia treatment
Student’s usual symptoms of hyperglycemia (list below):  	

• Check	Urine	Blood for ketones every  	hours when blood glucose levels are above  	mg/dL.
• For blood glucose greater than  	mg/dL AND at least  	hours since last insulin dose, give correction dose of
insulin (see correction dose orders).
• Notify parents/guardians if blood glucose is over  	mg/dL.
• For insulin pump users: see Additional Information for Student with Insulin Pump.
• Allow unrestricted access to the bathroom.
• Give extra water and/or non-sugar-containing drinks (not fruit juices):  	ounces per hour.
Additional treatment for ketones:  	
• Follow physical activity and sports orders. (See Physical Activity and Sports)
If the student has symptoms of a hyperglycemia emergency, call 911 (Emergency Medical Services) and contact the student’s parents/guardians and health care provider. Symptoms of a hyperglycemia emergency include: dry mouth, extreme thirst, nausea and vomiting, severe abdominal pain, heavy breathing or shortness of breath, chest pain, increasing sleepiness
or lethargy, or depressed level of consciousness.

Insulin therapy		
Insulin delivery device:
Type of insulin therapy at school:	Syringe
Adjustable (basal-bolus) insulin	Insulin pen
Fixed insulin therapy	Insulin pump
No insulin	

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Adjustable (Basal-bolus) Insulin Therapy
• Carbohydrate Coverage/Correction Dose:	Name of insulin:  	
• Carbohydrate Coverage:
Insulin-to-carbohydrate ratio:	Lunch: 1 unit of insulin per  	grams of carbohydrate
Breakfast: 1 unit of insulin per  	grams of carbohydrate	Snack: 1 unit of insulin per  	grams of carbohydrate

Carbohydrate Dose Calculation Example

 Total Grams of Carbohydrate to Be Eaten  =  	Units of Insulin
Insulin-to-Carbohydrate Ratio

Correction dose:	Blood glucose correction factor (insulin sensitivity factor) =  	

Target blood glucose =  	mg/dL

Correction Dose Calculation Example

 Current Blood Glucose – Target Blood Glucose  =  	Units of Insulin
Correction Factor

Correction dose scale (use instead of calculation above to determine insulin correction dose):
Blood glucose               to               mg/dL, give               units      Blood glucose               to               mg/dL, give               units Blood glucose               to               mg/dL, give               units      Blood glucose               to               mg/dL, give               units See the worksheet examples in Advanced Insulin Management: Using Insulin-to-Carb Ratios and Correction Factors
for instructions on how to compute the insulin dose using a student’s insulin-to-carb ratio and insulin correction factor.
When to give insulin:
Breakfast
Carbohydrate coverage only
Carbohydrate coverage plus correction dose when blood glucose is greater than  	mg/dL and  	hours since last insulin dose.
Other:  	
Lunch
Carbohydrate coverage only
Carbohydrate coverage plus correction dose when blood glucose is greater than  	mg/dL and  	hours since last insulin dose.
Other:  	
Snack
No coverage for snack
Carbohydrate coverage only
Carbohydrate coverage plus correction dose when blood glucose is greater than  	mg/dL and  	hours since last insulin dose.
Correction dose only: For blood glucose greater than  	mg/dL AND at least  	hours since last insulin dose.
Other:  	

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Fixed Insulin Therapy	Name of insulin:  	
 	Units of insulin given pre-breakfast daily
 	Units of insulin given pre-lunch daily
 	Units of insulin given pre-snack daily
Other:  	
Parents/Guardians Authorization to Adjust Insulin Dose
Yes
Yes	No
No	Parents/guardians authorization should be obtained before administering a correction dose. Parents/guardians are authorized to increase or decrease correction dose scale within the following range:	
		+/–  	units of insulin.	
Yes	No	Parents/guardians are authorized to increase or decrease insulin-to-carbohydrate ratio within the following	
		range:  	units per prescribed grams of carbohydrate, +/–  	grams of carbohydrate.	
Yes	No	Parents/guardians are authorized to increase or decrease fixed insulin dose within the following range:
+/–  	units of insulin.	
Student’s self-care insulin administration skills: Independently calculates and gives own injections. May calculate/give own injections with supervision.
Requires school nurse or trained diabetes personnel to calculate dose and student can give own injection with supervision. Requires school nurse or trained diabetes personnel to calculate dose and give the injection.

Additional information for student with insulin pump

Brand/model of pump:  	Type of insulin in pump:  	

Basal rates during school: Time:                      Basal rate:                          Time:                       Basal rate:                          Time:                       Basal rate:                         

Time:  	Basal rate:  	 Time:  	Basal rate:  	

Other pump instructions:  	

Type of infusion set:  	

Appropriate infusion site(s):  	

For blood glucose greater than  	mg/dL that has not decreased within  	hours after correction, consider pump failure or infusion site failure. Notify parents/guardians.
For infusion site failure: Insert new infusion set and/or replace reservoir, or give insulin by syringe or pen.
For suspected pump failure: Suspend or remove pump and give insulin by syringe or pen.

Physical Activity		
May disconnect from pump for sports activities:	Yes, for  	hours	No	
Set a temporary basal rate:	Yes,  	% temporary basal for  	hours	No	
Suspend pump use:	Yes, for  	hours	No	

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Additional information for student with insulin pump (continued)

Student’s Self-care Pump Skills	Independent?	
Counts carbohydrates	Yes	No	
Calculates correct amount of insulin for carbohydrates consumed	Yes	No	
Administers correction bolus	Yes	No	
Calculates and sets basal profiles	Yes	No	
Calculates and sets temporary basal rate	Yes	No	
Changes batteries	Yes	No	
Disconnects pump	Yes	No	
Reconnects pump to infusion set	Yes	No	
Prepares reservoir, pod, and/or tubing	Yes	No	
Inserts infusion set	Yes	No	
Troubleshoots alarms and malfunctions	Yes	No	

Other diabetes medications

Name:  	Dose:  	Route:  	Times given:  	

Name:  	Dose:  	Route:  	Times given:  	

Meal plan

Meal/Snack	Time	Carbohydrate Content (grams)	
Breakfast		 	to  		
Mid-morning snack		 	to  		
Lunch		 	to  		
Mid-afternoon snack		 	to  		

Other times to give snacks and content/amount:  	

Instructions for when food is provided to the class (e.g., as part of a class party or food sampling event):  	

Special event/party food permitted:	Parents’/Guardians’ discretion	Student discretion
Student’s self-care nutrition skills:
Independently counts carbohydrates
May count carbohydrates with supervision
Requires school nurse/trained diabetes personnel to count carbohydrates

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Physical activity and sports

A quick-acting source of glucose such as	glucose tabs and/or	sugar-containing juice must be available at the site
of physical education activities and sports.
Student should eat	15 grams	30 grams of carbohydrate	other:  	
before	every 30 minutes during	every 60 minutes during	after vigorous physical activity	other:  	 If most recent blood glucose is less than  		mg/dL, student can participate in physical activity when blood glucose is
corrected and above  	mg/dL.
Avoid physical activity when blood glucose is greater than  	mg/dL or if urine/blood ketones are moderate to large. (See Administer Insulin for additional information for students on insulin pumps.)

Disaster plan

To prepare for an unplanned disaster or emergency (72 hours), obtain emergency supply kit from parents/guardians.
Continue to follow orders contained in this DMMP.
Additional insulin orders as follows (e.g., dinner and nighttime):  	

Other:  	

Signatures

This Diabetes Medical Management Plan has been approved by:

Student’s Physician/Health Care Provider	Date

I, (parent/guardian)  	, give permission to the school nurse or another qualified health care professional or trained diabetes personnel of (school)  			to perform and carry out the diabetes care tasks as outlined in (student)  		Diabetes Medical Management Plan. I also consent to the release of the information contained in this Diabetes Medical Management Plan
to all school staff members and other adults who have responsibility for my child and who may need to know this information to maintain my child’s health and safety. I also give permission to the school nurse or another qualified health care professional to contact my child’s physician/health care provider.

Acknowledged and received by:

Student’s Parent/Guardian	Date

Student’s Parent/Guardian	Date

School Nurse/Other Qualified Health Care Personnel	Date

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