1. No category

Medication Administration Skills Checklist
Person Trained
Position
Date
Diabetes and Glucagon
Procedure Guidelines:
Identifies location of
Diabetes Individual
Healthcare plan and has an
understanding of the
information it contains.
(location of glucagon)
Understands the basics of
Diabetes
States the signs/symptoms
of hyperglycemia.
Trainee Initials of
acknowledgement/
comments
School Nurse initials of
acknowledgement of
skill/comments
**
District RN initials of
acknowledgement of
competency/skill
States the signs/symptoms
of hypoglycemia.
Familiar with diabetic
testing supplies
Familiar with disposal
guidelines of sharps
Demonstrates mixing of
glucagon in syringe.
Demonstrates proper
injection technique and
correct sites.
States correct aftercare
**
**
**
Acknowledges when to
contact EMS
Documents all action taken
during a diabetic event.
** Indicates where initials are required by the school nurse
I have provided training to the staff member named above to assist students with self-administration of
medication at school according to State Guidelines and CMCSS policy and procedures. She/He has
demonstrated knowledge and understanding through demonstration and testing.
District R.N. Signature
5/12/14
Date
HEA-F094a
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I have observed the trainee demonstrate the skill of glucagon injection as delegated by the District RN.
The trainee can identify diabetic students and is aware of where to find their Individual Healthcare Plan.
School Nurse Signature
Date
I have been instructed in the CMCSS medication policy and administration procedures. I understand that
I am to assist with the self-administration of medications to students according to these procedures as
delegated to me. I understand that I am to report immediately to the school nurse any new orders,
change in medication orders, changes in student health status, and discovery of a medication error. I
understand that I may not delegate this task to any other person.
Staff Signature
5/12/14
Date
HEA-F094a
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