DiabeticCampNameAssessment1.docx
Pediatric Diabetic Camp Assessment
Facility Data
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Date: Phone Number: Number of Campers:
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Address: Numbers of Staff/Volunteers:
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Guidelines
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Complete this review, using the following scale:
NA = Not Applicable
1 = Needs Work (Unsatisfactory)
2 = Gets By (Marginal)
3 = Meets Requirements
4 = Exceeds Requirements
5 = Exceptional
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Staff and Volunteer Training/Requirements
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(5) = Exceptional
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(4) = Exceeds Requirements
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(3) = Meets Requirements
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(2) = Gets By
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(1) = Needs Work
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All staff and volunteers must be medical professionals either licensed or a student
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All staff must have a background check
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All staff must be trained in these areas:
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Routine Diabetes Management
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Lifestyle Modifications for Type 2 Diabetes
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Treatment of Diabetes-Related Emergencies
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Familiarity with signs and symptoms of hypo-/hyperglycemia and indications of blood glucose testing
Staff/Volunteers undergo a competency test of the above skills _____Yes or _____No
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The Camp includes the following licensed medical staff and medical volunteers. Please mark with X if present.
____ Medical Director who is licensed physician knowledgeable of managing Type 1 and Type 2 Diabetes
____Licensed Physician on-site at all times during camp programs and on call at all times
____Physician Assistant present on the camp grounds
____3 to 5 nurses on site at all times
____Diabetes educators present on camp grounds at all times
____At least 2 pharmacists on site at all times
____Registered Dietician present to create appropriate and balanced meals for campers
____2 Licensed Psychologists
____At least 1 Social worker
____Nursing students ____Pharmacy students ____Physician Assistant students
____Nurse Practioner students ____Dietetic students ____Social Work students
Prior Knowledge of Campers
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(5) = Exceptional
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(4) = Exceeds Requirements
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(3) = Meets Requirements
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(2) = Gets By
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(1) = Needs Work
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Comprehensive health history completed by the family on file for all campers
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Completed health evaluation form on file
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Copy of the home insulin regimen on file
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Documented knowledge of any psychological concerns/issues on file
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Form completed by family noting any religious practices on file
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Form completed by family noting any cultural or religious restrictions
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Emergency Contacts on file for all campers
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Medical Materials and Medications
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(5) = Exceptional
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(4) = Exceeds Requirements
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(3) = Meets Requirements
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(2) = Gets By
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(1) = Needs Work
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Glucose testing materials and treatments readily available
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Extra insulin pump supplies (batteries, catheter sets, etc.) readily available
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Appropriate containers available throughout the camp to discard sharp objects
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Gloves available at all times throughout camp
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Camp Activity Requirements
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(5) = Exceptional
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(4) = Exceeds Requirements
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(3) = Meets Requirements
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(2) = Gets By
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(1) = Needs Work
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Physical Activities provided
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Social Activities available
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Diabetes education classes available (management, dietary decisions, appropriate physical activity, coping mechanisms if applicable)
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Alternate activities available when necessary
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Opportunities for meaningful interactions
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Financial Information
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(5) = Exceptional
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(4) = Exceeds Requirements
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(3) = Meets Requirements
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(2) = Gets By
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(1) = Needs Work
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Scholarships/Payment Plans
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Additional funds to provide snacks for campers
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Vouchers available to assist families with funding transportation to and from the camp site
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