FORM 4

ST. MICHAEL-ALBERTIVILLE PUBLIC SCHOOLS

Section 504 Plan

STUDENT INFORMATION
Name:

Date of Birth:

School: St. Michael Elementary

Grade: 4

Parent/Guardian Name:
Address:
Phone:

Email:

Case Manager: Kathy Ellsworth

Date of 504 Plan Meeting: September 2, 2015

PROVISION OF FAPE
The student who is the subject of this individualized plan has been
determined to be a student with a Section 504 disability and entitled to
the provision of a free appropriate public education (FAPE) as defined by
the federal Section 504 regulations.
After the student has been determined to have a Section 504 disability,
the students multidisciplinary team should convene and answer the
following questions to determine how FAPE will be provided to the student
who is the subject of this plan.
1. Describe the nature of the concern:
_____has Type One Diabetes.
2. Describe the basis for the determination of disability:
_____was diagnosed with Type One Diabetes on September 21, 2014 by Dr. Chen
which has the potential to affect ____ school day.
3. Describe how the disability affects a major life function:
_____ may exhibit symptoms of high/low blood sugars; which may include
Hypoglycemia: shaky, tired, sluggish, paleness, glazed eyes, hungry, thirsty,
flushed face, stomach ache, sweating, dizziness, blurred vision, irritability,
crying, confusion, drowsiness, lack of coordination, trembling, abdominal pain,
and nausea.
Sever hypoglycemia: unconsciousness and seizures
Hyperglycemia/Diabetic Ketoacidosis: Early signs: paleness, hungry,
jittery, thirsty, tired, excessive urination, and appetite.

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FORM 4
Later Signs: dehydration, decreased urination, headache, muscle aches,
abdominal pain, malaise, vision changes, nausea, and vomiting.
Very Late Signs: very deep, but not labored, breathing and sweet odor of
breath.
4. Does the student only require any of the following programs, aids,
services, accommodations, supports or interventions?
__X___ Yes
_____ No
If the answer is Yes, mark which of the following programs, aids, services, accommodations,
supports and/or interventions are necessary for the student to receive FAPE:
__X___ Access to School Health Services or Nursing Services
__X___ Administration of Medication
__X___ Individual Health Plan
____ Regular Education Interventions
_____ Regular Education Behavior Contract or Support Plan
_____ Other (describe):
If the answer to Question 2 is Yes, attach a copy of any preexisting written
plans (such an Individual Health Plan) or programs. If no written plan or program
is available, provide a description of the program, aids, services,
accommodations, supports or interventions that are or will be in place.
5. SCHOOL: Describe the accommodations, services and/or supports
Accommodation, Service and/or
Supports
A school nurse or health
paraprofessional will be at STME at all
times during student school hours.
One staff member will be trained to
assist ______ with his diabetes care if
the School Nurse or Health
Paraprofessional is unavailable.
Blood Sugar Check:
10:25(snack) and 1:55(Pre-bus/van),
whenever _____ feels his blood
glucose levels are high or low, or
when symptoms of high or low
glucose levels are observed. The
nurse or health paraprofessional will
follow Emergency Care Plan.
After lunch, ______ will report what he
ate to the nurse or health
paraprofessional.

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Location

Person Responsible

STME

Nurse

STME

Nurse, health
paraprofessional,
classroom teacher

Health Office

Nurse or health
paraprofessional

Health Office

Nurse or health
paraprofessional

FORM 4
The school nurse will provide staff
with a general overview of diabetes,
including symptoms to look for, and
typical care, and show a picture of
____ so he can be identified by the
end of September.
During the first week of the school
year, the school nurse will provide
teachers, paraprofessionals, and bus
driver who work directly with _____ a
copy of the Emergency Care Plan with
the Dear Teacher letter, written by
the parent, attached to it.
Insulin and/or other diabetes
medication will be administered at
the times and through the means
designated in Grants Emergency
Care Plan for both scheduled doses
and corrective doses.
_______ symptoms of high and low
blood glucose levels and how to
respond to these levels are set out in
his Emergency Care Plan.
____ shall be provided with privacy for
blood glucose monitoring and insulin
administration.
_____ shall eat lunch at the same time
each day or earlier if experiencing
hypoglycemia. He will be given
enough time to finish lunch. A snack
and quick acting source of glucose
will always be immediately available
to Grant.
_____ classmates will be given a letter
composed by the school nurse to take
home to be given to parents
explaining what Diabetes is. This
letter will not identify Grant.
______ will be allowed, if he chooses,
to give his classmates an overview of
diabetes.
The School Nurse will be immediately
notified, and, in turn, will promptly
notify parents if ______ is exhibiting if
any of the following situations arise:
Symptoms of severe low blood
sugar such as continuous
crying, extreme tiredness,
seizure, or loss of
consciousness.

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Media Center

Nurse

Classrooms

Nurse.

Health Office

Nurse or health
paraprofessional

STME

Nurse

Health Office

Nurse or health
paraprofessional

Cafeteria

Nurse or health
paraprofessional

Classroom

Nurse

Classroom

________ and teacher

Health Office

Nurse or health
paraprofessional

FORM 4

Blood glucose test results are

below 50 or are below 60 15
minutes after consuming juice
of glucose tablets.
Symptoms of severe high
blood sugar such as frequent
urination, presence of ketones,
vomiting or blood glucose level
above 400.
Grant refused to eat to take
insulin injection or bolus.
Any significant injury.
_____ primary classroom teacher will
maintain Grants 504 Plan,
Emergency Care Plan, and Dear
Teacher letter in a location that is
easily accessible to staff.
______ teacher will keep a copy of his
504 Plan, Emergency Care Plan, and
Dear Teacher letter in her
substitute folder.
_____ will have a regular time for
snacks and be allowed to have
additional snacks. Grant will be
permitted to eat a snack no matter
where he is.
If treats will be given in class, _____
should bring it to the health office
with treat package prior to eating it.
The Health Office will be notified prior
to taking _____ out of the building.
The Health Office will be notified at
least 2 days prior to taking ______ on
a field trip or off school grounds.
______ will be permitted to participate
in all 4th grade field trips without
restriction. The school nurse or
health paraprofessional will be
available on the site of the 4th grade
field trip and will make sure that _____
diabetes supplies will travel with him.
_____ parents will not be required to
accompany him on 4th grade field
trips.
_____ will be permitted to perform the
following care tasks without
supervision:
Recognize the need to test
blood sugar

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Classroom

Teacher

Classroom

Teacher

Classroom and
Health Office

Teacher, nurse, or health

paraprofessional

Health Office

Nurse or health
paraprofessional

Classroom

Teacher

Classroom

Teacher

Field trip
location

Nurse or health
paraprofessional

______

Nurse or health
paraprofessional

FORM 4

Ask for an escort to the nurses

office
Test blood sugar
Leave the classroom to use the
bathroom or to get water
______ is permitted to perform the
following care tasks with supervision:
Counting and summing the
total carbohydrates to be
eaten.
Calculating the correct insulin
does (or meal bolus) for
carbohydrates.
If blood sugars are high,
identifying the amount of
correction insulin needed.
Adding the meal bolus and
correction dose for total
injection amount.
Injection of insulin.
Testing of ketones.
Record in his log book.
The nurse or health paraprofessional
will perform the following care tasks:
Test blood sugar if _____ is
incapable.
Provide a sugar source and
encourage ingestion when
_____ is awake but not
functioning normally from low
blood sugars.
Inject glucagon if _____ is
unconscious from low blood
sugars or is unable to swallow.
Determining insulin amounts
surrounding physical activity.
Determine when ketones are to
be tested.
_____ medical supplies will be kept in
the Health Office.
_____ will be permitted to carry the
following supplies with him
throughout the school day: Glucose
Monitor, Test Strips, Lancing Device,
Lancets, Alcohol Wipes, Ketone Strips,
Insulin Pen, Syringes, Glucagon
Emergency Kit, Glucose Tablets, and
Juice or other source of

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Health Office

Nurse or health
paraprofessional

Health Office

Nurse or health
paraprofessional

Health Office

Nurse or health
paraprofessional
Teacher, Nurse, or health
paraprofessional

STME

FORM 4
carbohydrates.
The school will notify the parents
immediately if ____ is to remain after
school. A snack may need to be
given.
_____ will be permitted, at his
discretion, to carry and access freely
a fast acting sugar source in the
event he feels low. He is not required
to test himself prior to eating a
tablet.
_____ is permitted to participate fully
in physical education classes except
as set out in his Emergency Care
Plan.
Physical Education teachers will have
a copy of the Emergency Care Plan
and Dear Teacher letter. They will
be able to recognize symptoms of
high or low blood sugar levels, and
have tablets available. The Phy-ed
teachers will call the nurse or health
paraprofessional after giving him a
tablet.
If _____ begins using an insulin pump,
a 504 team meeting will be convened
to adjust his 504 plan.
The school nurse or health
paraprofessional will have _____ blood
glucose meter, a quick acting source
of glucose, and water available at the
site of physical education class.
_____ shall be permitted to have
immediate access to water by
keeping a water bottle in _____
possession and at his desk. He may
use the drinking fountain without
restriction.
_____ shall be permitted to use the
bathroom without restriction.
_____teacher will permit him to leave
class at any time _____feels it is
necessary to manage his diabetes.
When low blood sugars are
suspected, _____teacher will have
someone walk with him to the health
office and wait until the school nurse
or health paraprofessional is
available. The teacher will notify the
nurse or health paraprofessional that

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Office

Principal, Dean of
Students, or Teacher

Grant

Gym

Teachers

Gym

Teachers

STME

504 Team

Gym and
Health Office

Phy-ed Teachers, nurse,

and health
paraprofessional

STME

Teacher, nurse, and health

paraprofessional

STME

School Staff

Classroom and
Health Office

Teacher

FORM 4
_____is on his way.
When _____asks for assistance, or any
staff member believes Grant is
showing signs of high or low blood
glucose levels, the staff member will
immediately call the nurse or health
paraprofessional and stay with
_____at all times. _____will never be
sent alone with suspected high or low
blood glucose levels.
If _____is unconscious and unable to
eat, drink or swallow, a school nurse
or health paraprofessional will need
to inject him with Glucagon. Specific
instructions about the administration
of Glucagon can be found in the
Health Office. If Glucagon is
administered 911 will be called and
parents will be notified immediately.
Any staff member who finds _____
unconscious will immediately contact
the office, and the office will do the
following immediately in order:
1. Contact the school nurse or
health paraprofessional. They
will confirm the blood glucose
level with a monitor and
immediately administer
glucagon. If no monitor is
available glucagon should be
administered.
2. Call 911
3. Contact _____parents and
physician at the emergency
numbers listed in order below:
_____, Mother,
_____, Father,
_____, Step-Father, 651-2028869
_____, Grandmother,
_____, Grandfather,
_____, Grandmother,
Dr. Swartz, Endocrinology
Doctor, Park Nicollet St. Louis
Park 952-993-3900
Dr. Chen, Primary Care Doctor,
Park Nicollet Maple Grove,
952-993-1440

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STME

Staff

STME

Nurse or health
paraprofessional

STME

Staff

FORM 4
_____will be permitted to check blood
sugar levels before or during class,
classroom assessments, NWEA, and
DIBELS to ensure appropriate blood
sugar levels. If blood sugar levels are
not with in the target range of 80-160
he will be allowed to retake his test at
a later time or date without
consequence.
_____will test his blood sugar level
before taking the MCAs. If blood
sugar levels are not with in the target
range of 80-160 he will be allowed to
take the test at a later time.
If _____needs to take breaks to use
the water fountain, bathroom, check
blood glucose, or treat hypoglycemia
or hyperglycemia during a test or
other activity, he will be given extra
time to finish without penalty.
_____shall be given instruction to help
him make up any classroom
instruction missed due to the
diabetes care without penalty.
_____shall not be penalized for
absences required for medical
appointments and/or for illness. The
parents will provide documentation
from his treating health care
professional if otherwise required by
school policy.
The school nurse, health
paraprofessional, and other staff will
keep _____diabetes confidential
except to those with a legitimate
educational interest to access this
information.
_____will be treated in a way that
encourages him to eat snack on time,
and to progress toward self-care with
his diabetes management skills.
In the event of emergency evacuation
or lock down situation, _____504 plan
and Emergency Care Plan will remain
in effect.
The school nurse or health
paraprofessional will be responsible
for transporting _____ diabetes
supplies and equipment in the case of
an emergency evacuation.

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Health Office

Nurse or health
paraprofessional

Classrooms

Teachers, nurse, or health

paraprofessional

Teachers

Classroom

STME

Attendance tracker and

parents

STME

Staff

Classroom and
health office

Teacher, nurse, and health

paraprofessional

Classroom

Teacher

FORM 4

Describe any related services. Examples of related services include but

are not limited to transportation, counseling, nutrition, orientation and
mobility, service coordination, assistive technology
Accommodation, Service and/or
Supports
If _____and/or his parents expresses
an interest in him participating in any
specific extracurricular activity, a 504
Team Meeting will be convened to
review and amend the 504 plan, as
the Team determines appropriate.

Location

Person Responsible
504 Team and parents

6. Describe accommodations, services and/or support provided by

PARENTS:
Prior to the start of each school year, _____parents will provide the School
Nurse with a copy of the Diabetes Management Plan that has been
developed by _____doctor.
_____parents will supply snacks needed in addition to or instead of any
snacks supplied to all students.
_____parents will provide the carbohydrate content information for snacks
and meals brought from home.
Provide school with the Dear Teacher letter from _____.
_____parents will notify the 504 Team if they sign _____up for an
extracurricular activity at least two weeks prior to the start of the activity.

7. Describe accommodations, services and/or support provided by

STUDENTS:
NA
8. Accommodations For Extracurricular And Nonacademic Activities:
NA
Will
the
student
have
the
opportunity
to
participate
nonacademic/extracurricular activities with his/her nondisabled peers?
_____ Yes
_____ Yes, with supports (describe)

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in

FORM 4

9. Anticipated 504 Plan Review Date: This 504 Plan will be reviewed at least
annually by a group of individuals knowledgeable about _____. The District will
invite _____parents, the school nurse, and the buildings 504 coordinator. School
Staff or _____parents may ask to review the 504 Plan periodically during the
school year.
10.

List of Participants (Name and Role/Title):

_______________

Parent
Parent

Julie Winkelman

Nurse

Corey Lahr

Principal

Kathy Ellsworth
Coordinator

Dean

of

Students/504

I, the parent/legal guardian of the student named above, was given the opportunity
to participate in the development of this Section 504 Plan and agree with the Plan
as developed. I also have been given a copy of my Section 504 Procedural
Safeguards and have had the opportunity to review those safeguards.
NOTE:
Parental consent is required in order initially place the student in Section
504.

Parent/Guardian Signature
Copy of 504 Plan given to parents on
.

Date
by

The Case Manager is responsible for informing all responsible teachers,

staff and administration of their responsibilities for the implementation of
this 504 Plan. Please indicate below the date and manner in which this
information was provided. The Case Manager also is responsible for
monitoring to ensure that all teachers, staff and administrators are
implementing the Plan as written.

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