RCJTC DiabetesHypoglycemiaRequest

Diabetes Hypoglycemia Emergency Action Plan

Student Photo

Emergency Contacts

Name: (H) (W) (C)
1.
Name: (H) (W) (C)
2.
Name: (H) (W) (C)
3.

Signs and Symptoms

Optimum Level (Range) of Blood Sugar is:

Location of Sugar Treatment

WHEN IN DOUBT - TREAT

Select one treatment, provided by parent, from the following:
6 oz. (125 ml) of fruit juice/drink (junior juice box) OR
3 - 4 tsp. (10 - 15 ml) of sugar (3 - 4 parckets) OR
6 oz. (125 ml) of regular pop (not diet type) OR
3 - 4 tsp. (10 - 15 ml) of honey OR
4 - 5 glucose tablets OR

CALL PARENTS TO INFORM THEM

Wait 10 - 15 minutes. If there is no improvement, repeat the above treatment.

DO NOT LEAVE THE STUDENT ALONE!

If the student is unconscious, having a seizure or unable to swallow DO NOT give food or drink.
*Roll the student on his/her side
*Call 9-1-1
*Inform parents/guardians
Submitted by I acknowledge that transportation procedures will apply.

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