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732. 8419 Fax 613. 732. 2874 Website www. rcjtc.on.ca Email trans rcjtc.on.ca F.02. 02 DIABETES HYPOGLYCEMIA EMERGENCY ACTION PLAN Student s Name Place Student s Picture Here Classroom Teacher Parent/Guardian/Emergency Contacts Prioritize calls i.e. 1 2 3 Parent H 613- W 613- C 613- Other Names please print EMERGENCY TREATMENT FOR HYPOGLYCEMIA Signs and Symptoms Sweating Trembling Dizziness Mood changes Hunger Headaches Blurred vision Extreme tiredness/paleness Other please specify Optimum Level Range of Blood Sugar is Location of Sugar Treatment With Student WHEN IN DOUBT TREAT Select one treatment provided by parent from the following 6 oz. Renfrew County Joint Transportation Consortium 999 Cecelia Street Pembroke ON K8B 1A4 Telephone 613. 125 ml of fruit juice/drink junior juice box OR 3 4 tsp* 10 15 ml of sugar 3 4 packets OR 4 5 glucose tablets 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 Roll the student on his/her side having a seizure or unable to swallow Call 9-1-1 DO NOT give food or drink Inform parents/guardians Rte AM PM Original School Copy Renfrew County Joint Transportation Consortium The personal information you have provided on this form and any other correspondence relating to transportation is collected by the Renfrew County Joint Transportation Consortium RCJTC under the authority of the Education Act R*S*O. 1990 c*E*2 ss. 58. 5 265 and 266 as amended* The information will be used to arrange appropriate transportation and to give information to employees and transportation providers to carry out their job duties. In addition the information may be used to deal with matters of health and safety or discipline and is required to be disclosed in compelling circumstances or for law enforcement matters or in accordance with any other Act. The information will be used in accordance with the Education Act the regulations and guidelines issued by the Minister of Education governing the establishment maintenance use retention transfer and disposal of pupil records. For questions about this collection speak to the General Manager of the RCJTC 999 Cecelia St* Pembroke 613-732-8419. 125 ml of fruit juice/drink junior juice box OR 3 4 tsp* 10 15 ml of sugar 3 4 packets OR 4 5 glucose tablets 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 Roll the student on his/her side having a seizure or unable to swallow Call 9-1-1 DO NOT give food or drink Inform parents/guardians Rte AM PM Original School Copy Renfrew County Joint Transportation Consortium The personal information you have provided on this form and any other correspondence relating to transportation is collected by the Renfrew County Joint Transportation Consortium RCJTC under the authority of the Education Act R*S*O. If there is no improvement repeat the above treatment. DO NOT LEAVE THE STUDENT ALONE If the student is unconscious Roll the student on his/her side having a seizure or unable to swallow Call 9-1-1 DO NOT give food or drink Inform parents/guardians Rte AM PM Original School Copy Renfrew County Joint Transportation Consortium The personal information you have provided on this form and any other correspondence relating to transportation is collected by the Renfrew County Joint Transportation Consortium RCJTC under the authority of the Education Act R*S*O. 1990 c*E*2 ss. 58. 5 265 and 266 as amended* The information will be used to arrange appropriate transportation and to give information to employees and transportation providers to carry out their job duties.

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