School’s Open REAL soon. Many people have asked me this week for a copy of our 504 plan which we proposed to the school. There are many out there if you look around and certainly no one owns the market on what a 504 plan looks like and by looking at a few, you may grab a pointer or two from more than one; it’s all about what is right for your child. This was ours and as a FYI—this became the accepted 504 plan.
(Cover page:)(Name omitted)
Initial Draft: 504 Plan
Presented for Review: (DATE)
XYZ School District
Respectfully Submitted by (names omitted) for Perusal (DATE)
(Page 1)(Name Omitted)
Initial Draft 504 Plan
Presented for Review: (Date)
(Name of) School/School District
School Term: Open ended; to continue as long as (Name Omitted) is a student; amended as mutually agreed upon
- Both high blood sugar levels (hyperglycemia) and low blood sugar levels (hypoglycemia) affect (Name Omitted)’s ability to learn and to perform major life activities such as eating and caring for oneself, as well as seriously endangering his health. (Name Omitted)’s blood glucose levels must be maintained in the 80-150 range for optimal learning and testing of academic skills. (Name Omitted) has a recognized disability, type 1 diabetes that requires the accommodations and modifications set out in this plan to ensure that he has the same opportunities and conditions for learning and academic testing as his classmates with minimal disruptions of his regular school schedule and with minimal time away from the classroom. Steps to prevent hyperglycemia and hypoglycemia, and to treat these conditions if they occur, must be taken in accordance with this plan.
At least 3 (name of) School/School District Staff members (The School Nurse, Principal and/or Principal’s designee) will receive training or has been trained to be an Authorized Diabetes Care Provider (ADCP) and that an ADCP will be available at all times during school hours, during extracurricular activities and on field trips (which sometimes may be mutually agreed that one of (Name Omitted)’s parents will serve as an ADCP for class trips) to oversee (Name Omitted)’s diabetes care in accordance with this 504 plan including performing or overseeing insulin injections, blood glucose tests, ketone tests, and responding to hypoglycemia and hyperglycemia I including administering glucagon. A written back-up plan, including all of the names of the ADCPs, will be implemented to ensure that an ADCP is available in the event that the school nurse is unavailable.
- Any staff member who has primary care for (Name Omitted) at anytime during school hours, extracurricular activities (see #1), and/or during field trips and who is not an ADCP, shall receive training to be a Diabetes Care Assistant Provider (DCAP). Primary care is defined as the staff member who is IN-CHARGE of a class or activity in which the student participates. An ACP or other designated trained staff member shall accompany (Name Omitted) on field trips when parent is not present and provide accommodations in accordance with these provisions. The parents will NOT be required to accompany (Name Omitted) on field trips or any other school activity. All trips and/or school activities will be discussed a minimum of 30 days in advance so proper steps are taken that (Name Omitted) does not miss an opportunity to partake in an event with his classmates. If parents are unavailable the school will arrange coverage as per school policy. A copy of that exact portion of the school policy must be attached to the 504 plan upon agreement.
- The school nurse will coordinate with (Name Omitted)’s parents a snack and meal schedule that is consistent with the schedule of his classmates to the closest extent possible. The school nurse or school staff member responsible for class activity will also notify (Name Omitted)’s parents no less than two days in advance of any expected changes in the school/classroom schedule that may affect (Name Omitted)’s meal and snack times or exercise routine (i.e. Field Day, field trips, runs, walks, classroom parties, and/or the equivalent.)
- ALL school personnel will permit (Name Omitted) to eat a snack at anytime and in any part of the school, school grounds, any associated school trips, and/or while waiting or riding in school buses, to treat hypoglycemia either measurable or if (Name Omitted) feels as if his blood sugar is dropping.
- (Name Omitted) shall be permitted to eat a snack anywhere on the school grounds including but not limited to classrooms, library, gym, auditorium, and school bus.
- (Name Omitted) shall have immediate availability and access to treatment of hypoglycemia without the necessity for him to travel to the health office.
- (Name Omitted) shall be permitted to carry on his person at all times (including but not exclusive to: Pockets, backpack, desk etc) glucose tablets, glucose gel, glucagon, insulin pump, insulin needles, snack, glucometer, lancets and incidental supplies. (Name Omitted) will also be permitted to keep his supplies and equipment in his locker (if he chooses).
- (Name Omitted) shall be permitted to use the bathroom and water foundation AS NEEDED and may just signal to the person in charge that he is leaving. Any questions arising to the need/frequency to use the bathroom facilities will be directed to (Name Omitted)’s parents and not to (Name Omitted) at any time. he will be permitted to keep a water bottle in his possession or at his desk.
- High or low blood sugar levels should be treated immediately
- (Name Omitted) shall be permitted to participate fully in all school sponsored activities; including but exclusive to: sports, field trips, enrichment programs, that occur after regular school hours without restrictions and with all of the accommodations and modifications including necessary supervision identified and set out in this plan.
- (Name Omitted) shall eat his lunch at the same time each day or earlier if hypoglycemic and/or as deemed necessary by the ADCP (should a change be needed, (Name Omitted)’s parents will be informed on the same day of the occurrence). If (Name Omitted) is experiencing hypoglycemia and is buying lunch, then he will be placed at the front of the line.
- (Name Omitted) shall be permitted to take exams and other academic tests at other times, if he is affected by high or low blood glucose levels at the time of the regular testing, without penalty. (Name Omitted) shall be permitted to have extra time to complete his classroom work if he is affected by a high or low blood glucose levels or needs to excuse himself for either use of the bathroom facilities and/or use of the water fountain in addition to perform a blood glucose test and/or to treat hypoglycemia or hyperglycemia. This procedure is to be followed for any and all testing including testing mandated by NY State, which has contingency procedures in place for such occurrences.
- (Name Omitted) shall be provided with instructions to help him makeup classroom time and assignments due to any of the mentioned conditions in #12. Additionally, (Name Omitted) will be provided with extra time to complete class work, out of school assignments, and/or tests without penalty if he is affected by high or low blood glucose levels or needs to take breaks to use the water fountain or bathroom facilities, perform a blood glucose test, or treat high or low blood glucose symptoms.
- Parents will be notified by Instructors, Principal and/or Guidance Counselor of any and all assignments, quizzes, tests, and project grades that are below a C+ as academic performance may be adversely impacted by hypo/hyper-glycemia. Notification will be communicated immediately in writing upon grade determination during any time (Name Omitted)s average falls below C+ during the school year. (Name Omitted) will be provided with an opportunity to makeup classroom time and instruction, or re-take tests, in accordance with paragraphs 12 and 13.
- Given the choice, (Name Omitted) will be permitted to check his blood glucose level with his meter, administer insulin (injection or pump), or eat a snack in the classroom, health office, or any location in the school, on the bus and/or on field trips and school sponsored off-site activities.
- (Name Omitted) MUST ALWAYS be escorted to the health office when he feels low, or feels he is ‘going’ low and chooses to treat the reaction outside of the classroom, gym or another area of the school.
- In addition to supplies kept in (Name Omitted)’s locker (if he chooses), in ample supply of supplies and food/drink pertaining to (Name Omitted)’s diabetes will be kept in the health office. The School Nurse will give a minimum notice of three days to (Name Omitted)’s parents if any of these supplies should be running low with less than a three-day supply remaining.
- (Name Omitted)’s diabetes supplies and snacks, including insulin and glucagon, are also to be maintained in the health office but diabetes supplies are also needed to travel with (Name Omitted) on field trips or to other off-site events. Nurse, and/or Health office staff, ADCPs, and other designated staff members should be made aware of the location of (Name Omitted)’s supplies and will make arrangements to ensure that (Name Omitted)’s supplies (either additionally enough taken from home after contacting (Name Omitted)’s parents or taken from the health office) to accompany (Name Omitted) on school sponsored activities away from the school location.
- Substitute teachers and health aides need to be made aware of (Name Omitted)’s diabetes and be prepared and capable of providing compliance with the provisions stated herein. Teachers (or in the case when the absence is sudden, the Administrative Office of the school/Principal) MUST provide substitute teacher(s) with written instructions regarding (Name Omitted)’s diabetes care and an emergency plan, which also includes a list of al ADCPs at the school. Substitute teachers will receive training on how to recognize hyper/hypo-glycemic reactions and know how to contact an ADCP and/or nurse if needed.
- At the beginning of each school year, all ADCPs and DCAPs of the (Name of school district) will have participated in a diabetes education program provided by the health resource/nurse of the school or from within the district.
- It is important that (Name Omitted) travel, as usual, with his peers on the (name of school district) bus as s/he has for years and not be segmented out for any special transportation mode. This may be accomplished with cooperation. (Name Omitted)’s bus drive (including both regular and/or ALL substitute drivers) shall be trained in the administration of glucagon, the recognition and treatment of both hyperglycemia and hypoglycemia. (Name Omitted)’s diabetes supplies, including an edible snack, shall be kept on (Name Omitted)’s person at all times and under NO circumstances should they be taken away. (Name Omitted) will not be prohibited from eating a snack or otherwise treating a low blood sugar. ANY bus driver who transports (Name Omitted) when neither an ADCP or DCAP is present MUST BE a Bus Driver Diabetes Care Provider (BDDCP). Should the bus driver not agree with and/or understand a particular action (Name Omitted) is taking dealing with his diabetes care, under no circumstance should any discussion be engaged WITH (NAME OMITTED) regarding his activity on the bus, but rather, the parents and school officials (Principal) should be notified immediately that the bus driver would like to speak about any particular action or course of events. Of course general inquiries and/or questions to ascertain an emergency situation may be made as needed.
- (Name Omitted) should not be penalized for absences or partial attendance in any classes including gym for required medical appointments and/or illness and shall be provided with an opportunity to make-up missed assignments, classroom work, and tests in accordance with paragraph 12, 13, and 14 herein.
- If (Name Omitted) so desires, he shall be provided with privacy for testing and/or insulin administration.
- (Name Omitted) shall have access to the school nurse or ADCP upon request
- Encouragement and being equally treated among (Name Omitted)’s peers is crucial. (Name Omitted) must not be treated in a way that discourages him from eating snacks on time, or from completing his own blood glucose ‘checks’, insulin administration, or his general diabetes care and management. With the exception of (Name Omitted)’s medical needs, he should be treated as other students without diabetes and students should be encouraged to do the same.
- (Name Omitted)’s diabetes will be kept confidential except to the extent that (Name Omitted) or his parents decide to openly communicate about it with others or what is needed to be shared with school personnel (contract and full-time) regarding this 504 plan.
- Parent should be notified immediately in the following situations:
- Symptoms of severe low blood sugar such as crying, extreme tiredness, or loss of consciousness.
- Blood Glucose level below 60
- Symptoms of severe high blood sugar such as frequent urination, presence of ketones (school nurse), or blood glucose level above 300
- Under any/all circumstances should (Name Omitted) refuse to perform a blood glucose check, administer a bolus/insulin shot, and/or refuse to eat.
- (Name Omitted)’s grades drop below a C+
- Any injury
- Act in a behavior deemed abnormal
- Parents will supply all diabetes supplies and snacks to the school nurse/health office and replenished upon request from the school nurse. Parents will come in within one week of the end of school to pick up any remaining diabetes supplies, meters, and snacks.
- In the event of an evacuation, shelter-in-place, or emergency situation should arise either during (Name Omitted)’s presence on the school grounds or partaking in school sponsored events off premise; (Name Omitted)’s 504 plan will remain in full force and effect and an ADCP will be available to provide diabetes care as outline by these plans. The ADCP will maintain contact with (Name Omitted)’s parents during said time in order to provide updates regarding (Name Omitted)’s diabetes care. (Name Omitted)’s parents will be permitted to retrieve (Name Omitted) as soon as parents are able to safely retrieve him without any unnecessary delays and when officials deem it is safe to do so. The school nurse or other primary ADCP will be responsible for transporting diabetes food and supplies to the area students have been directed during the emergency.
- Should (Name Omitted) be selected for participation in any school activities (sports, school and/or club competitions or activities etc), at no time will participation be denied when practice or meetings have been missed as a result of a diabetes-related illness or medical appointment. If more than one consecutive day of practice is missed as a result of a diabetes-related illness or medical appointment, participation will be at the discretion of the school assigned moderator and/or coach in consultation with (Name Omitted)’s parent(s).
- All of the enclosed should be in effect as (Name Omitted)’s 504 plan and is enforceable and effective as the 504 Pan under the applicable federal and state laws.
- Insulin will be administered in accordance with the guidelines of the (Name of School District) and those guidelines will be attached to (Name Omitted)’s 504 plan. Should insulin be required, (Name Omitted)’s parents will be contacted by a school nurse. If parents are unavailable, and (Name Omitted) is unable to perform the administering of insulin himself, the school nurse will administer the insulin as per doctor’s orders.
- All attachments outlining health procedures within the school district dealing with a child with diabetes will be attached to the final 504 document.
- A copy of the mutually agreed and signed copy of the 504 plan will be given to Mr. and Mrs. (Name Omitted) with all attachments as stated.
- It will be the responsibility of the School District to make sure that the 504 plan designed for (Name Omitted) follows him and is adhered to whether there is a change in the staff of teachers, schools, and/or district administrations.
School Health Official/Nurse/Doctor/Print Name Date
School Staff/Title/Print Name Date
School Staff/Title/Print Name Date
School Staff/Title/Print Name Date
School Staff/Title/Print Name Date
I hope it helps a little bit.
I am a diabetes dad.
Please visit my Diabetes Dad FB Page and hit ‘like’.