The American Diabetes Association's Safe at School program publishes this plan as the school's medical orders for a student with type 1 or type 2 diabetes. It covers supervision level, glucose and CGM monitoring, insulin devices and dosing tables, low and high glucose management, glucagon, exercise settings, supplies and disaster planning. Schools can build a 504 Plan, IEP or other accommodations plan from it.
The parent or guardian completes the red sections on page 1 (demographics, schedule, contacts, supplies and history) and sends the form to the diabetes provider before school starts. The diabetes provider (physician, PA or APRN) completes the black sections 3 to 10 on pages 2 to 5 and signs, and the parent and school nurse or designee sign acknowledgments.
Completed by the parent or guardian on page 1 and sent to the medical provider before the start of school. It covers the student's name, school, grade and school point of contact, diabetes type and date diagnosed, arrival and dismissal times, how the student travels, meal and snack times, physical activity days and times, and two parent or guardian contacts with a preferred contact method. A student photo can be added at the top.
Also a parent section. Families supply at least three days of diabetes supplies, including insulin, meter and strips, syringes or pen needles, ketone strips, low treatments and snacks, glucagon and pump supplies, and review expiration dates monthly. In a disaster or extended field trip, a school nurse or designee takes the supplies to the student. The parent also reports loss of consciousness, seizure or glucagon use, and DKA or diabetes hospitalization, in the last two years.
The provider selects Full Support, Supervision or Self-Care separately for glucose monitoring, glucose management, and insulin administration, which covers carb counting, dose calculation, giving insulin and responding to device alarms. Full Support means the school nurse and trained staff do all care as state law permits; Supervision means trained staff assist and encourage independence; Self-Care means the student manages that skill independently. Also answer whether the student self-carries supplies and whether a smartphone is medically necessary.
Check when glucose is monitored: before meals and with physical complaints or illness (both defaults, the latter with ketone testing), for symptoms, before or after physical activity, before leaving school, or other. For CGM users, specify brand and model and whether remote monitoring by school staff is optional or medically necessary. The section lists when to do a fingerstick instead, such as symptoms that don't match the sensor or a reading still below 70 mg/dL 15 minutes after treating a low.
Select all devices that apply: multiple daily injections by syringe, pen or smart pen, injection via i-Port, a bolus calculator app, or an insulin pump with brand and model, noting whether it is an automated insulin delivery (AID) or open-source AID system. In section 6, check the rapid-acting, ultra-rapid or short-acting insulin used for food and correction, and any long-acting or ultra-long-acting insulin with time, dose, route and indication, such as a routine school, overnight field trip, disaster or pump failure dose.
Choose when mealtime insulin is given: prior to the meal (10 to 15 minutes recommended for rapid-acting insulin), at the time of the meal (for ultra-rapid insulin or the iLet pump), 'may advance' once eating patterns are consistent, a partial dose before the meal for unpredictable eaters on pumps, or after the meal as soon as possible. The form reminds staff to provide substitute carbohydrates when a student doesn't finish a meal.
Page 3 sets the meal dose as a food dose (Table A: carb ratio or fixed meal dose by time block) plus a correction dose (Table B: correction formula with target glucose and correction factor, or a sliding scale), or defers to the pump or smart-device bolus calculator. Set how often corrections may be given, when to check ketones, and whether the school nurse and parents may adjust doses within stated limits. The page has its own provider signature and date.
Set the treatment threshold, the grams of carbohydrate per treatment and the glucose target, or rely on the printed defaults. A table sets the number of treatments by glucose level and CGM trend arrow, with arrow keys for each CGM brand, and the section lists fast-acting carbohydrates to use. For severe (Level 3) lows, check the glucagon product and dose. Exercise features for pumps and AID systems, pump suspension limits and extended-exercise snacks are also set here.
Set the glucose level and the time after a meal or bolus that trigger high-glucose management, with defaults that differ for pump and injection users. The section covers fluids, ketone checks before any correction, separate actions for trace or small versus moderate or large ketones, infusion site changes for pump users, when to hold physical activity and when to call emergency services. It also tells the school when to send glucose logs to the provider.
The student's health care provider (physician, physician assistant or advanced practice registered nurse) signs, dates and prints a name. The parent or legal guardian signs an acknowledgment giving permission for the school nurse or trained diabetes personnel to carry out the plan, consenting to share it with school staff who need to know, and allowing the nurse to collaborate with the provider. The school nurse or designee also signs and dates.
Download the current version from the source each time; forms change without notice.
Diabetes Medical Management Plan
Plan de manejo médico de la diabetes
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The parent or guardian completes the red sections on page 1, covering demographics, schedule, contacts, supplies and recent severe events, and sends it to the diabetes provider. The provider, a physician, physician assistant or advanced practice registered nurse, completes the black sections 3 to 10 on pages 2 to 5 and signs. The parent and school nurse or designee sign acknowledgments.
ADA says the DMMP should be updated annually or whenever the child's regimen, self-management level or school circumstances change. The form's header has a blank school-year range for that reason. For dose changes during the year, the page 3 dosing table is designed as a single page update order form with its own provider signature.
Yes. ADA publishes a fillable Spanish version, Plan de manejo médico de la diabetes, dated January 2026 alongside the English form. It has the same five pages and numbered sections, with red sections for the parent or guardian and black sections for the diabetes provider, ending in the same approval signatures.
Yes. ADA's sample cover letter describes the DMMP as the primary document for the student's diabetes care and says it can be used to develop a 504 Plan, an Individual Education Program (IEP) or another written accommodations plan. Some school systems also require a completed DMMP before providing nutrition accommodations.