Form PC-262-10 Insulin Depended Diabetic Supplemental Form

OMB Control No. 0420-xxxx Expiration Date xx/xx/xxx Peace Corps

Insulin Dependent Diabetic Supplemental Documentation FORM

Dear Medical Provider:

Your patient has applied to serve as a Peace Corps Volunteer and has reported having insulin dependent diabetes. During Peace Corps service, every Peace Corps Volunteer with diabetes will face dramatic changes to living conditions, diet, and level of physical activity. In order to protect the health of our Volunteers, we ask you to review the issues below with your patient and provide us with your written recommendations.

Please check each box confirming the corresponding issue has been addressed with the applicant.

• I have recently discussed with the applicant insulin strategies and recommendations that can be used when adjusting to a new diet. (Since hypoglycemia is much more threatening in the short term than mild loss of glycemic control, please consider instructing your patient to temporarily reduce his/her sliding scale dosing until a better understanding of the local diet is achieved.) Recommendations:

• I have recently discussed with the applicant insulin strategies and recommendations that can be used during a “sick day,” or a day when gastrointestinal issues cause a decreased oral intake or potential for increased fluid losses. Recommendations:

For Applicants on Continuous Subcutaneous Insulin Infusion:

I have recently discussed with this applicant recommendations regarding switching to a multiple daily injection (MDI) regimen in the event of an insulin pump failure. Recommendations:

OR

• N/A Applicant does not require the use of an insulin pump.

• I have recently discussed with this applicant recommendations for the proper care and maintenance of all diabetes-related monitors and equipment. Below is a list of the devices and necessary disposables:

Device(s)/Disposables	Manufacturer/Model Number

Provider Signature: _____________________________________________

Provider Name: _____________________________________________

Address: _____________________________________________

_____________________________________________

Telephone: _____________________________________________

Email: _____________________________________________

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