Fillable Diabetes Section 504 Accommodation Plan (USDA Food and Nutrition Service)

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Diabetes Section 504 Accommodation Plan (USDA Food and Nutrition Service)

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1
Diabetes Section 504 Accommodation Plan
School Year: _______ School DBN and Name: _______________________
Student & Family Information
Student Name:
Disability/Diagnosis:
Type _____Diabetes
OSIS #:
DOB:
Classroom Teacher:
Grade:
Paraprofessional Name (if applicable):
Parent/Guardian Preferred Spoken Language:
504 Team Members
List name of 504 Coordinator, all 504 Team members, and their titles.
Name
Role
1.
504 Coordinator
2.
Parent/Guardian
3.
Office of School Health Nurse (if applicable)
4.
5.
6.
Objectives/Goals of this Plan
Diabetes can cause blood glucose (sugar) levels to be too high or too low, both of which may affect the
student’s ability to learn as well as seriously endanger the student’s health both immediately and in the
long term. The goal of this Plan is to provide the related aids and services and accommodations needed
to maintain blood glucose within a safe range, and as close as possible to the student’s target range
set by the provider, and to respond appropriately to levels outside of this range in accordance with the
instructions provided by the student’s licensed health care provider.
The 504 Coordinator will coordinate with the other 504 Team members to arrange the student’s
diabetes care in New York City Department of Education (DOE) programs and activities.
2
This Plan shall be reviewed before the end of each school year or more often if necessary, and
amended at the time of the review, if necessary.
Definitions Used In This Plan
DOE Program or Activity
: Any program or activity sponsored by the DOE, including PA/PTA
sponsored after-school programs or extracurricular activities in a DOE building.
Diabetes Medication Administration Form and Addendum (DMAF)
: The Office of School Health
medication order form and any addendums pertaining to the diabetes care regimen, including the
medication needs of a student with diabetes. The DMAF and any addendums are completed by the
student’s health care practitioner, signed by the parent/guardian, and reviewed by the Office of School
Health.
Once the student’s DMAF for the school year is ready to be implemented, the 504 Team will review this
Plan and make any necessary revisions to comply with the new/revised DMAF.
Trained Non-Licensed Personnel (TNP)
: Non-medical school personnel who are trained in basic
diabetes knowledge and have received training coordinated by the school nurse in diabetes care,
including the recognition and treatment of hypoglycemia, recognition of hyperglycemia, the
performance of blood glucose monitoring, glucagon administration and the performance of ketone
checks, will perform these diabetes care tasks in accordance with applicable laws, rules, and
regulations. Trainings include appropriate subsequent referrals to the school nurse as indicated on the
DMAF. All TNP will be provided a copy of this Plan with details regarding signs and symptoms of hypo-
and hyperglycemia highlighted, and their roles, and will receive training on the specifics of the
student’s DMAF.
1. Provision of Diabetes Care
1.1. At least _______ staff members will receive training to be a TNP, and either a school
nurse, substitute school nurse or Contract Nurse, or TNP will be available at the site
where the student is at all times during school hours, during DOE extracurricular
activities, and on DOE field trips to provide diabetes care in accordance with this
Plan and as directed in the DMAF.
Be sure to list all TNP in Section 2.1.
1.2. The nurse shall perform the following diabetes care tasks in accordance with
student’s DMAF, and shall receive training on performing any of the following, if
needed
o determine dose and administer insulin
o administer glucagon if needed
o check ketones if needed, in accordance with DMAF
o keep appropriate records of insulin administration and other blood glucose
treatment
o communicate with parent/guardian regarding diabetes treatment
o communicate with the student’s healthcare provider regarding diabetes
treatment
o communicate with Office of School Health physician if needed
o coordinate with Principal to initiate training for school staff
3
o _______________________________________________
o _______________________________________________
1.3. If the student has been assigned a paraprofessional, the paraprofessional is to be
trained as a TNP and will perform the following diabetes care tasks in the classroom,
or wherever the child is [Check those appropriate], to the maximum extent possible:
⃣ adhere to Standard Precautions for Infection Control principles regarding hand
hygiene, Personal Protective Equipment (PPE), safe device handling, safe
needle/sharps disposal planning
⃣ check blood glucose levels with finger-stick device
⃣ monitor readings on Continuous Blood Glucose Monitor (CGM)
⃣ check ketones if needed, in accordance with DMAF, and refer to school nurse if:
⃣ Ketones are moderate or large
⃣ Student feels unwell
⃣ Other: __________________
⃣ administer glucagon and call 911 in the event of an emergency and keep
appropriate record of such; notify nurse and school administration
⃣ give fast-acting glucose or snack in the event of hypoglycemia [Insert from
DMAF: blood glucose ____________ mg/dL]; notify nurse
⃣ give water and monitor in the event of hyperglycemia [Insert from DMAF: blood
glucose ____________ mg/dL]; notify nurse
⃣ communicate with parent/guardian regarding the above
⃣ __________________________________________________________
⃣ __________________________________________________________
⃣ __________________________________________________________
⃣ __________________________________________________________
If student’s blood/sensor glucose via the blood glucose monitoring or CGM is ______ mg/dL or
higher, paraprofessional will give water and monitor student, check for ketones, as outlined in
the student’s DMAF, and inform the school nurse. Student generally should not be kept in the
nurse’s office for high blood glucose readings unless student does not feel well or is receiving
insulin treatment.
As per the DMAF addendum, if the CGM is ___ or below, or the symptoms do not match the
number and/or arrows, the paraprofessional may perform a finger-stick blood glucose test.
When the student’s assigned paraprofessional is not available, a paraprofessional with the
appropriate training will provide this diabetes care.
4
2. Trained Non-Licensed Personnel
2.1 The following school staff members will receive Level 2 training to carry out their
responsibilities as a TNP (list names and titles and dates of training):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2.2 The Office of Pupil Transportation ensures that any bus driver or bus attendant who
transports the student has undergone safety training in accordance with applicable
New York State Education Department requirements.
2.3 Any staff member who is not a TNP and who is responsible for the student at any
time during school hours, DOE extracurricular activities, or during DOE field trips will
be provided Level 1 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 TNP.
The staff members who have received this training are (list name, title, and date of
training):
[Include Physical Education teachers and coaches in this list. See Section 5.]
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2.4 The following individuals who have volunteered to be trained will receive training on
how to administer glucagon, in addition to the training outlined in 2.3:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Student’s Level of Self-Care and Location of Supplies and
Equipment
3.1 (a) As stated in the DMAF:
The student skill level to test their blood glucose is:
⃣ Nurse/adult must check blood glucose
⃣ Student to check blood glucose with adult supervision
⃣ Student may check blood glucose without supervision
5
The student’s skill level to self-administer insulin is:
⃣ Nurse-Dependent Student: nurse must administer medication
⃣ Supervised student: student self-administers, under adult supervision
⃣ Independent Student: Self-carry/Self-administer licensed provider attested
Skill level designated for school hours as set forth above should be maintained at
any time and in any location at the school, at field trips, at sites of DOE
extracurricular activities, and on school buses.
(b) The student needs a TNP to perform or needs supervision with the following
other diabetes care tasks (e.g., provide verbal cues while the student monitors their
blood glucose and self-administers insulin, verify correctness of math for carb
counting). Specify level of independence with the task:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3.2 The student and/or TNP (including assigned paraprofessional) will be permitted to
carry the following diabetes supplies and equipment at all times and in all locations
(please include phone and/or smart watch here, if applicable): [Consult the DMAF
and school nurse to complete this section]
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3.3 Diabetes supplies and equipment that are not kept on the student and additional
supplies and will be kept at: [Typically, the classroom and nurse’s section/medical
room, or with TNP (excluding CGM monitoring device and Personal Diabetes
Manager equipment)]
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3.4 Parent/guardian is responsible for providing diabetes supplies and food to meet the
needs of the student as ordered in the DMAF.
6
4. Snacks and Meals
4.1 (a) Meals and snacks will occur consistent with the DMAF.
(b) DMAF includes breakfast orders: Yes ⃣ No ⃣
4.2 Carbohydrate content information for snacks and meals provided by the DOE Office
of Food and Nutrition Services (OFNS) is available on the OFNS website, or upon
request to the school’s on-site School Food Service Manager.
4.3 A snack or fast-acting source of glucose must always be immediately available to the
student.
4.4 The teacher will notify parent/guardian of any changes in the snack or meal
schedule at least 48 hours in advance, or as soon as possible if 48-hour notice
cannot be provided.
4.5 The student will be permitted to eat a snack no matter where the student is. [Insert
additional language, as applicable to the individual student consistent with the
parent’s/guardian’s instructions, such as:
The student should always be permitted to
eat any foods that they prefer, including special celebratory snacks such as
cupcakes. At snack time, they should be permitted to choose from the school-
provided snack or home-provided snack.
]
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4.6 The parent/guardian will supply snacks needed in addition to or instead of any
snacks supplied to all students.
4.7 The parent/guardian will provide carbohydrate content information for snacks and
meals brought from home.
4.8 Adjustments to snack and meal times will be permitted in response to changes in
schedule upon request of parent/guardian consistent with the DMAF.
5. Exercise and Physical Activity
5.1 The student shall be permitted to participate fully in physical education classes and
team sports consistent with the student’s DMAF.
5.2 Physical education instructors and sports coaches will receive training in accordance
with Section 2.3 and will receive a copy of this Plan.
5.3 Responsible school staff members will make sure that the student’s blood glucose
meter, a fast-acting source of glucose, and water are always available at the site of
physical education class and DOE team sports practices and games.
7
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 student’s possession and at the student’s desk, and/or 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
Administration, and Treating High or Low Blood Glucose Levels
7.1 The student’s level of self-care is set out in section 3 above including which tasks
the student can do by themselves and which must be done with the assistance of,
or wholly by, either a school nurse or a TNP.
7.2 Blood glucose monitoring will be done at the times designated in the student’s
DMAF, whenever the student feels their blood glucose level may be high or low, or
when symptoms of high or low blood glucose levels are observed. Nurse(s) or TNP
should always minimize the amount of time the student may miss classroom
instruction when deciding how to perform or assist a student with their blood
glucose testing, with the most appropriate care of the student being priority.
7.3 Insulin and/or other diabetes medication will be administered at the times and by
the route (e.g., syringe, pen, or pump) prescribed on the student’s DMAF and/or
addendum for both scheduled doses and doses needed to correct for high blood
glucose levels. Nurses should always minimize the amount of time the student may
miss classroom instruction when deciding how to administer insulin, or, for nurses
and TNP, to assist a student with administration of insulin, with the most
appropriate care of the student being priority.
7.4 The 504 Team must discuss and determine the least restrictive environment for
diabetes care based on the individual needs of the student and not available
resources. Diabetes care may be provided in the classroom or wherever the student
is, nurse’s office, or other location, with a goal of minimizing missed instruction time
and maximizing time with peers.
Specify the location for each diabetes care task:
Lunchtime insulin will be administered __________________________.
Correction insulin will be administered __________________________.
Snack time insulin will be administered __________________________.
Blood glucose will be monitored _____________________________.
Ketones will be monitored __________________________.
7.5 The student shall be provided with privacy for blood glucose monitoring and insulin
administration if the student desires.
8
7.6 The student’s usual symptoms of high blood glucose are:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
The student’s usual symptoms of low blood glucose are:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Instructions for how to respond to these levels are set out in the DMAF.
7.7 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 TNP 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.
7.8 If student becomes unconscious:
1. Glucagon will be administered immediately by paraprofessional or other TNP
without checking the blood glucose and 911 must be called.
2. Contact the school nurse or TNP (if nurse is not available).
3. Paraprofessional, nurse, or other school personnel should call 911 and remain
with the student.
4. A finger-stick blood glucose shall be done when the student regains
consciousness, if 911 has not arrived.
5. Contact the main office.
6. Contact student’s parent/guardian and physician at the emergency numbers
provided below.
7.9 If consistent with DMAF orders and does not interfere with treatment, the student
may request that school staff, including physical education instructors and coaches,
store the student’s insulin pump if the student chooses not to wear it during physical
activity or any other activity.
9
8. Transportation, Field Trips, and Extracurricular Activities
8.1 [504 Coordinator: check one of the following as applicable after confirming with
school’s Transportation Coordinator] The DOE shall provide to accompany student
on their bus ride to and from school each day:
⃣ not applicable;
⃣ transportation nurse;
⃣ transportation paraprofessional;
⃣ door-to-door transportation with attendant only; or
⃣ stop-to-school transportation with no attendant.
8.2 The student will be permitted to participate in all DOE field trips and DOE
extracurricular activities (such as all DOE after-school activities, sports, clubs, and
enrichment programs) without restriction and with all of the accommodations and
modifications, including necessary diabetes care by identified school personnel, set
out in this Plan. The student’s parent/guardian will not be required to, but may
choose to, accompany the student on field trips or any other school activity.
8.3 The DOE will provide a nurse to administer insulin as needed, or other trained staff
to administer all other diabetes care required by a student with diabetes (including,
but not limited to, blood glucose monitoring, recognizing and treating hypoglycemia,
providing snacks and access to water and the bathroom), as required by their
DMAF, for all DOE field trips and DOE extracurricular activities, and will make sure
that the student’s diabetes supplies travel with the student when accompanying the
student on such trips or at such activities. If this staff is not the school nurse, the
school nurse shall instruct the assigned staff on the student’s 504 Plan and DMAF. In
the event the assigned nurse or staff member informs DOE that they are
unavailable, DOE will immediately use best efforts to obtain a replacement nurse or
staff member.
8.4 To the maximum extent possible, the student’s teacher shall notify parent/guardian,
principal, and school nurse of any upcoming field trips with at least 2 weeks’
advance notice so that a trip nurse request can be submitted, and at least 30 days
in advance for all extended day or overnight trips so that any additional medical
orders can be obtained and reviewed and a trip nurse can be requested.
8.5 List all DOE activities and programs the student plans to participate in and specify
who will provide diabetes care during the activity/program, what type of diabetes
care that individual will provide, and the date they will be/have been trained (e.g.,
school breakfast, chess club, choir):
Program:
Care Needed:
Individual to Provide Care:
Date of Training:
10
Program:
Care Needed:
Program:
Care Needed:
Individual to Provide Care:
Date of Training:
Program:
Care Needed:
Individual to Provide Care:
Date of Training:
Program:
Care Needed:
Individual to Provide Care:
Date of Training:
8.6 If the student is participating in a non-DOE after-school program, the parent may
contact the 504 Coordinator with concerns about the program’s ability to
accommodate the student’s diabetes under their independent non-discrimination
obligations.
9. Classroom and Test Accommodations
9.1 If the student is affected by high or low blood glucose levels at the time of regular
or standardized testing, the student will be permitted to take the test at another
time without penalty.
9.2 For students who use a CGM, the following accommodations will be used during
testing [Check those appropriate, if any]:
Student will be permitted to access phone/smart watch, as needed, for diabetes
care consistent with most recent DMAF and addendum. Classroom teacher or
proctor will monitor student’s phone/smart watch use to preserve test integrity.
⃣ Alternate location
⃣ Placing phone in a secure location and using only a receiver/smart watch to
monitor blood glucose
⃣ Disconnecting phone/smart watch from internet (such as using Airplane mode
but enabling Bluetooth) to allow student to continue using phone/smart watch
to monitor glucose
⃣ ______________________________________________________________
11
⃣ ______________________________________________________________
⃣ ______________________________________________________________
⃣ ______________________________________________________________
9.3 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 as needed to finish the test or other
activity without penalty.
9.4 The student shall be given instruction to help them make up any classroom
instruction missed due to diabetes care without penalty.
9.5 Absences required for medical appointments and/or for illness shall be excused. The
parent/guardian will provide documentation from the treating healthcare
professional if otherwise required by school policy.
10. Communication
10.1 The school nurse, TNP, and other staff will keep the student’s diabetes confidential
in accordance with applicable laws, rules, and regulations.
10.2 Encouragement is essential. The student should be treated in a way that encourages
the student to eat on time, and to progress toward self-care with their diabetes
management skills, in collaboration with the student’s endocrinologist and family.
10.3 The teacher or TNP will provide reasonable notice to parent/guardian and nurse
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 school nurse or Contract Nurse working with the student will be
provided with written instructions regarding the student’s diabetes care and a copy
of the student’s DMAF and this Plan. Each substitute teacher working with the
student will be provided with information regarding the student’s diabetes care and
how and when to immediately contact either a school nurse or a TNP.
10.5 When a new DMAF is submitted, the parent/guardian will notify the school nurse of
new diabetes management treatment, equipment, and/or supplies.
10.6 The TNP will notify the nurse of all glucose monitoring and treatments during the
school day and will provide the nurse with documentation of all diabetes
management responses by the end of the school day for inclusion in the student’s
medical record.
12
11. Emergency Evacuation and Shelter-In-Place
11.1 In the event of emergency evacuation or shelter-in-place situation, the student’s 504
Plan and DMAF will remain in full force and effect.
11.2 The school nurse or TNP will provide diabetes care to the student as outlined by this
Plan and the student’s DMAF, will be responsible for transporting the student’s
diabetes supplies and equipment, will attempt to establish contact with the student’s
parent/guardian and provide updates, and will receive information from
parent/guardian regarding the student’s diabetes care. The school nurse will also
receive and convey information to the student’s medical provider as indicated.
12. Parent/Guardian Notification
12.1 Notify Parent/Guardian of the Following Situations:
• Symptoms of severe low blood glucose levels, as [Insert specific symptoms of
severe hypoglycemia for this student]:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
• The student’s blood glucose test results are below ______ or are below ______
15 minutes after consuming juice or glucose tablets.
• Signs and symptoms of severe high blood glucose levels [Insert specific
symptoms of severe hyperglycemia for this student:
________________________________________________________________]
• Parent/guardian wishes to be contacted for (bg/sg) above __________ and
ketone test results. (DMAF must be followed for treatment).
• The student refuses to eat or take insulin injection or bolus.
• Any injury.
• Insulin pump malfunction whether or not remedied
• Use of the backup insulin route following the pump malfunction
• Other: __________________________________________________________
13
12.2 Emergency Contact Instructions
Call parent/guardian at numbers listed below. If unable to reach parent/guardian,
call the other emergency contacts or student’s health care providers listed below.
Emergency Contacts
Parent(s)/Guardian(s)
Parent(s)/Guardian(s):
Contact 2
Name:
Home Phone Number:
Work Phone Number:
Cell Phone Number:
Other Emergency Contacts:
Contact 1
Contact 2
Name:
Name:
Relationship to Student:
Relationship to Student:
Home Phone Number:
Home Phone Number:
Work Phone Number:
Work Phone Number:
Cell Phone Number:
Cell Phone Number:
14
Student’s Healthcare Provider(s):
Name:
Name:
Phone Number:
Phone Number:
Signatures
I have received the DOE Notice of Non-Discrimination under Section 504 and
Notice of Eligibility. By signing, I consent to the provision of accommodations to my child
as written above.
Approved and Received
Parent/Guardian Signature:
Date:
Approved and Received
School Administrator Signature:
Title:
Date:
Office of School Health Nurse Signature (if
applicable)
Date:
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Diabetes Section 504 Accommodation Plan (USDA Food and Nutrition Service)

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Completed 15 June 2022

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