Diabetes CGM Addendum

DIABETES – Continuous Glucose Monitor (CGM) Addendum to IHP
Utah Department of Health/ Utah State Board of Education

School Year:

Picture

Student:

DOB:

Grade:

School:

Parent:

Phone:

Email:

School Nurse:

School Phone:

Fax or Email:

If CGM requires calibration for treatment parent must check appropriate boxes and sign below.

All students using a CGM at school must have the ability to check a finger-stick blood glucose with a meter in the event of a CGM failure or apparent discrepancy. Test blood glucose with a meter if apparent disparity between CGM reading and symptoms!

Student Name:

DOB:

School Year:

My student is currently using one of the following continuous glucose monitoring systems which are FDA approved for making treatment decisions:
  • My student uses a Dexcom G5. Correction doses of insulin for hyperglycemia, or the intake of

carbohydrates for treating hypoglycemia can be determined at school based on the CGM if there is a glucose number and a directional arrow; unless otherwise directed by the provider. If the symptoms of the student do not match the CGM reading, check a finger-stick blood glucose with a meter.

  • I verify that I am responsible for calibrating the Dexcom G5 at home two times daily. I approve the school personnel or school nurse to treat hypoglycemia or give insulin doses based on the Dexcom G5.
  • My student uses a Dexcom G6. Correction doses of insulin for hyperglycemia, or the intake of carbohydrates for treating or preventing hypoglycemia can be determined at school based on the CGM if there is a glucose number and a directional arrow visible on the CGM; unless otherwise directed by the

provider. The “Urgent Low Soon Alert” signifies that a glucose of 55 mg/dl will be reached within 20 minutes. This should be treated based on the student’s emergency action plan. If the symptoms of the student do not match the CGM reading, check a finger-stick blood glucose with a meter.

  • I verify that I approve the school personnel or school nurse to treat hypoglycemia or give insulin doses based on the Dexcom G6.
  • My student uses a Freestyle Libre 14-day (Freestyle Libre 1) which is FDA approved for ages 18 and above.

For those 18 years old or older, correction doses of insulin for hyperglycemia, or the intake of carbohydrates for treating or preventing hypoglycemia can be determined at school based on the CGM if there is a glucose number and a directional arrow visible on the CGM; unless otherwise directed by the provider. Hypoglycemia should be treated based on the student’s emergency action plan. If the symptoms of the student do not match the CGM reading, check a finger-stick blood glucose with a meter. For those under 18 years of age treatment decision should be made based on a fingerstick blood glucose.

  • I verify that my student is 18 years of age or older and that I approve the school personnel or school nurse to treat hypoglycemia or give insulin doses based on the Freestyle Libre 14-day (Freestyle Libre 1).
  • My student uses a Freestyle Libre 2. Correction doses of insulin for hyperglycemia, or the intake of carbohydrates for treating or preventing hypoglycemia can be determined at school based on the CGM if

there is a glucose number and a directional arrow visible on the CGM, unless otherwise directed by the provider. The “Urgent Low” alert signifies that the glucose level has dropped to 55 mg/dl. This should be treated based on the student’s emergency action plan. If the symptoms of the student do not match the CGM reading, check a finger-stick blood glucose with a meter.

  • I verify that I approve the school personnel or school nurse to treat hypoglycemia or give insulin doses based on the Freestyle Libre 2.

Parent Signature:

Date:

Continued on Next Page
 

Student: 

DOB: 

School Year: 

My student is currently using the following continuous glucose monitoring system which is not FDA approved for making treatment decisions: 

☐ My student uses a Medtronic 530G with Enlite or 630G with Enlite or Guardian Sensor system which monitors glucose and will automatically turns off basal rates if the low threshold glucose is reached based on the CGM. When CGM alarms, treatment should be determined based on a finger-stick blood glucose. If the pump requests a calibration, the student can calibrate this on their own. The school nurse and the parent must put a plan in place for calibrating the CGM at school if the pump requests a calibration and the student is unable to calibrate the CGM independently. The reading used to calibrate the CGM must come from a finger-stick blood glucose using a meter. 

☐ I verify that I understand that the Medtronic Enlite and Guardian Sensors are not FDA approved for making treatment decisions. I approve the school personnel or school nurse to assist with calibrations (if desired). 

☐ My student uses a Dexcom G4. When the CGM alarms, treatment should be determined based on a finger-stick blood glucose. 

☐ I verify that I understand that the Dexcom G4 is not FDA approved for making treatment decisions. 

☐ My student uses a Medtronic 670G or 770G with Guardian Sensor system which is a hybrid closed loop system that monitors glucose and automatically adjusts the delivery of basal insulin based on the user’s glucose reading. When CGM alarms, treatment should be determined based on a finger-stick blood glucose. If the pump requests a calibration, the student can calibrate this on their own. The school nurse and the parent must put a plan in place for calibrating the CGM at school if the pump requests a calibration and the student is unable to calibrate the CGM independently. The reading used to calibrate the CGM must come from a finger-stick blood glucose using a meter. 

☐ I verify that I understand that the Medtronic Guardian Sensor is not FDA approved for making treatment decisions. I approve the school personnel or school nurse to assist with calibrations (if desired). 

☐ My student uses a Medtronic Guardian Connect system. When CGM alarms, treatment should be determined based on a finger-stick blood glucose. 

☐ I verify that I understand that the Medtronic Guardian Connect system is not FDA approved for making treatment decisions. 

Parent Signature: 

Date: 
 

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