I am a resident of Fauquier county with a now 7 year old daughter with Type 1 Diabetes (T1D). She was diagnosed at the age of 4 and within 3 months of diagnosis entered Kindergarten in Fauquier County Public schools. She is now in 2nd grade and has been in the public school system for only 16 months but has been through 8 school nurses during that time. We have had some traumatic experiences in dealing with this cycle of nurses, and at times have not had a nurse at all to care for my T1D child during the school day. I am personally writing to you to urge you to support SB1303, a crucial bill introduced by Senator Jeremy McPike that will ensure schools follow doctor-prescribed diabetes care plans and provide trained staff to assist students, no matter where they attend school or what nurse is or is not in the school. Currently, parents work with their child’s medical provider to develop a Diabetes Medical Management Plan (DMMP) that outlines the care needed to prevent life-threatening complications like seizures, diabetic ketoacidosis (DKA), and even death. While school nurses acknowledge and receive these plans, schools determine how (or if) they will implement them. In some cases, schools modify or outright reject these medical orders, placing children at serious risk and violating federal disability rights laws. This inconsistency deprives students of their right to a Free and Appropriate Public Education (FAPE) and forces parents to fight for basic accommodations that should already be guaranteed. Additionally, school policies have not kept pace with medical advancements. Many students now use Continuous Glucose Monitors (CGMs), which issue audible alarms when a student’s glucose reaches dangerous levels. SB1303 clarifies that trained school staff—not just nurses—can listen for these alarms and assist with scheduled checks. Similarly, insulin pumps, which replace multiple daily injections, should be managed by trained staff to prevent unnecessary school absences. Allowing properly trained personnel to handle these basic but essential tasks will minimize disruptions to students' education and reduce work absences for parents. This bill does not place additional burdens on teachers. It instead ensures that schools have clear guidance on their responsibilities, consolidates existing laws, and increases liability protections for staff who assist in diabetes care. More importantly, it provides consistency across Virginia, so families do not have to worry about their child’s safety and care being dependent on their school district’s interpretation of federal laws. As a parent, I know firsthand the constant vigilance required to keep my child safe. No family should have to fear for their child's health simply because their school lacks the necessary policies or trained staff. SB1303 is a practical, reasonable solution that ensures students with T1D receive the care they need to focus on learning—not just survival. I urge you to support this critical legislation and help ensure that all students in Virginia have the medical care they need to thrive in school. Please let me know if I can provide further information or discuss this issue further. Thank you for your time and consideration. Sincerely, Dr. Mary Bell Carlson

I am writing in support of SB 1303. I urge you to pass this bill. Diabetes management has advanced tremendously in recent years, and will continue to advance, and the law needs to catch up. I currently serve as a member of the Prince William School Board. I am also the parent of a 19 year old T1D student, diagnosed at age 10 months. We have followed the arc of diabetes care over the last 19 years through K-12 public school and into college. I cannot underscore enough that this bill is extremely important to our obligations to children with T1D in school. SB1303 is crucial to providing the best care for Virginia's schoolchildren with Type 1 Diabetes. The changes to SB1303 reflect ongoing dialogue between VASN, VSBA, and advocates, and coordinates with the VDOE Diabetes Management in Schools Manual and relevant America Diabetes Association guidance. The bill allows for undesignated glucagon in schools where there is a student with T1D. It also allows for a mechanism through a voluntary parent task force to improve dialogue between parents of T1D students and schools. In sum, SB1303 as amended includes all the changes requested by the Virginia Association of School Nurses. It resolves concerns of the Virginia School Board Association, and incorporates many language changes from the American Diabetes Association. This is a great bill and is very much needed. As a parent of a T1D student and as a member of my local school board and a member of the School Health Advisory Board, I urge you to vote in favor of SB1303.

As an elementary specialist who has at least one student each year with diabetes, I support this legislation. I understand that the recent changes tor this legislation have included all the changes from VASN and VSBA so that the perspectives of school nurses, school divisions, and parents were considered to make improvements to this legislation to make it both effectual and attainable across the Commonwealth.

Please support SB1303. As the parent of a type 1 diabetic child, I experienced firsthand the disregard of the Americans with Disabilities Act (ADA) with my own child in 2018 when he was first diagnosed. I brought the DMMP to my son’s school upon the start of a new school year. The school immediately did not want to comply with his endocrinologist’s orders, saying he was allowed to carry his own supplies and could check his blood sugar whenever he felt symptomatic. We were told it would be a “distraction” to other students for him to check his blood sugar in the classroom. I never thought my son’s diagnosis of a life-threatening disease would be considered a “distraction” as he was an honor student and could for the most part self manage his disease during the school day. We were told if he was experiencing a diabetic low, he was supposed to walk to the nurses office accompanied by another student. Do you realize that a blood sugar under 70 can cause a seizure? Why would you subject not only a diabetic child to walking a long distance to the nurses office, but also subject the student escorting him to a life-threatening situation? I immediately called for a 504 meeting and requested everyone who would have interaction with my child to attend, to include the principal and vice principal, school nurse, assistant nurse, teachers, etc. At the 504 meeting, I gave a handout to everyone in attendance. It included ADA laws and signs and symptoms of type 1 diabetic high and low blood sugars. I had my son attend and demonstrate a blood sugar check with a finger poke. After the meeting, the principal came up to me and apologized. She said they have always been used to doing things a certain way and didn’t realize that there were other things they should now be taking into consideration. These students have a life-threatening autoimmune disease that I hope many people never have to understand. The technology they use to manage this disease has been life changing. For those who are responsible for their care, we as parents, simply ask for a seat at the table. It’s been almost 7 years since my son was diagnosed and the state of Virginia still has no consistency on the management of type 1 diabetes in public schools. I’m urging you to support this bill so we can provide a standard guideline for these students to get schools to comply with federal laws. We want consistency statewide with those willing and able to provide for their care in a school setting. We send our children to school and expect them to follow the rules and teach them to follow laws. Schools should demonstrate the same in return. Thank you.

Vote yes for SB1303! It is clear by those opposing the bill that they do not understand the scope of what this bill can do positively. As a nurse such a key part of my role and scope is being able to delegate appropriately, and this bill would allow me to focus on more serious medical emergencies IF at the same time a student needed regular diabetic care. There are statements that continuous blood glucose monitors and insulin pumps are not best practice- then why do hundreds of children and adults with diabetes use them everyday? Most students are able to apply these devices themselves, often by the age of 7 years old (think 2nd grade). At my middle school, I simply store the extra supplies in the clinic and the students come and apply them on the rare occasion they fall off or the pump empties. There was a pre-K student who was thankfully wearing a CGM, and their blood glucose was normal at the start of nap time but while asleep they dropped into the 40s which is a situation requiring urgent response before an emergency occurs. So why would a school nurse rather explain to the other pre-K students why their classmate died in their sleep (because that is what would have happened had the student not been wearing a CGM) instead of going through some basic training themselves? In what other area of practice can nurses refuse to follow doctors' orders because it would mean more work for them? And if these are school nurses, then they should model how education is power! We have life saving EpiPens and Albuterol and Narcan in schools, this bill would allow us to have life saving glucagon as well! Some are saying the Diabetic Medical Management Plan is pages, while other plans are only one page. Insulin dependent diabetes has more gray areas than other medical emergencies- you're either having anaphylaxis or not to an allergen. To avoid anaphylaxis, you avoid the allergen. You cannot tell insulin dependent patients to avoid food because that will kill them or to avoid exercise, or to not get sick- this plan is comprehensive so it addresses as many of the anticipated gray areas as possible. I've applied CGMs to students before, I was trained by the nursing educators working with the student's provider as well as given resources to refer back to. By investing in my own knowledge and skills, I was able to help my student learn how to apply them and I no longer need to do so! Education is about investing in each student, in their health and wellness, and to help them stay in the classroom. Several of the responses make this sound like this is a daily or even hourly occurrence; and it's not. We are just asking that the safest and most effective care for students is accessible to them when or if these devices need replacing at school. Same with epipens, albuterol inhalers and even AEDs that the VASN fought so hard to get in schools. It's not a daily occurrence, but nurses are trained to be prepared in all situations and to be there in the worst case scenarios prepared to provide care to those in need. The VASN President boast of a " 'can do" attitude to increase the well-being of all children and employees," please do not allow school districts to limit the life saving care that nurses are able to provide for students in school, and in the absence of a nurse please allow the appropriate staff to be trained to help their students thrive! I am a school nurse and I can learn, and am willing to do what is rightfully within my scope of practice.

• Virgina School Nurses Association and The American Diabetes Association are against these changes. They recommend that we continue to use injectable insulin if the pump falls off or is not working during the school day. They recommend using glucometer if the CGM is not working. These practices do not hinder and are not a barrier to a student with diabetes education. They can continue their school day and participate in all school activities using injectable insulin and a glucometer. If the students pump and CGM are falling off or not working often enough to be a barrier to a child’s education we should be concerned , this would suggest other problems. • line 404 of bill 1303- The bill would like the principal to sign the DMMP. They are not normally a level 3 trained staff and have never signed a Health Treatment plan of any kind. The level Three trained staff do not sign the DMMP because it is a medical plan, and they are not medical. We must train them in how to use the DMMP. Level 3 and 2 people sign other forms saying we trained them, but this takes weeks to do completely. IT is extensive training. I think it might be appropriate for principals to be level 2 trained but not level 3. They are way too busy. They would not be able to use their skills enough to be properly trained. • Line 408 mentions that the DMMP can be shared with any person the parents want it to be shared with. I am assuming that person will be level 2 trained. It mentions coaches, school bus drivers and people in charge of extracurricular activities. To be able to read and understand a DMMP you must be level 3 trained, and the people discussed on this line can refuse training. We can show them the DMMP like we can show the principle the DMMP, but they will not be responsible for understanding it unless they go to insulin and glucagon (4-hour long class) and then get trained on that particular DMMP and are signed off on level 3 training. *A DMMP is 6 pages. An Asthma Action Plan is 1 page.

SB1303 has a substitute forthcoming which will address concerns raised in public comments, emails, and phone calls to state senators and delegates. Senator McPike’s upcoming substitute will incorporate and resolve all of the specific line-items given to him from the Virginia School Board Association, the Virginia Association of School Nurses, and concerns relevant to Virginia from ADA-org. The goal of SB1303 is to improve collaboration between parents, schools, and providers so everyone is working within the same laws and is clear on their application—aligning with 9 already existing Virginia codes and federal laws that support all of the amendments in this bill. Nonetheless, concessions made in the forthcoming substitute will reflect a willingness to address concerns in language without compromising the key components of this legislation. Contrary to some claims, a broad group of stakeholders—including national diabetes organizations, school nurses, physicians, parents, legislators, and attorneys collaborated in the creation of SB1303.

Vote yes for SB1303! I am the older sister of a student in Northern Virginia who has T1D. My brother is a vibrant and extremely intelligent child who enjoys going to school, learning new things, and seeing his friends. However, my family has been met with countless obstacles in our journey to secure equitable and empathetic care for our T1 loved one during the school day. The pushback against this bill breaks my heart for many reasons, but mostly it makes me scared for my brother's safety. I have seen, firsthand, what happens when a type one diabetic does not receive proper care. Seizures, loss of muscle control, blurry vision, extreme fatigue; none of these are conducive to a productive or caring school environment. It is devastating to imagine that those whom my family has entrusted my brother's care to are unwilling to protect him and support his education. I know that Virginia public schools can do better for our T1 students. This bill supports the Individuals and Disabilities Education Act and the legal right of all disabled students to a free and appropriate public education. We owe it to them to encourage a vote of yes for this bill in order to ensure that their rights are protected.

Vote yes for SB1303 I write to you as the parent of a child with Type 1 diabetes and as an RN. Parents and students with T1D want to partner with our schools. We want our schools to be a safe place for our child. School student health leadership has not partnered with parents, that is why we have gone to the extreme of seeking legislation to protect our children. In my own case I could not get a student health supervisor to return a phone or email, I had to seek out an associate superintendent through a formal grievance process to obtain requested care and accommodations. Unfortunately, the school systems hold the power and leave our students vulnerable. Many parents have experienced their school refusing to sign the DMMP, until they get medical providers to change orders. This leaves school nurses and Level 3 trained staff unable to provide any care or support for the student. This bill does not stop the school nurse or staff from contacting the medical provider for clarification of orders but does prevent parents from sending their child to school, knowing that NO care will be provided. That the only thing the school will do is call 911. Nothing in this bill states that routine care should be prioritized over any student having a medical emergency. As for reinserting insulin pumps and CGMs, nonmedical individuals are trained how to do this, and usually in a brief 30-45 minute training session. Have the school systems asked the device companies if they would be willing to come do annual training? Or asked if the local Endocrinologists clinics would hold training sessions? This could even be completed over zoom meetings! The technology is changing and improving short-term and long-term outcomes for our children. Why are school nurses and county school systems resisting using improved technology to improve their students' lives. Embracing this technology can keep kids in the classroom, limit interruptions to academic instruction for all students in the classroom. The improvement in blood sugar management also has long-term benefits. Reducing the damage to eyes, kidneys and vascular systems that increase medical costs and shorten the life span of a person with T1D. The backup plan is doing manual finger sticks every 2-3 hours, and injecting insulin every 2-3 hours. This is a greater workload for the nurse, and more interruption to the student's classroom environment. The American Nurses Association states, Evidence-Based Practice in nursing involves providing holistic, quality care based on the most up-to-date research and knowledge. Joint Commission requires trauma-informed, evidence-based practices for organization to be accredited. But schools are refusing this for care of T1D. Closed-loop algorithm insulin pumps, and CGMs are evidence-based practice. They can also reduce the trauma for student with fewer needle sticks, fewer events of being singled out as they are sent to the school office repeatedly. T1D students make up less than 1/2 percent of the students in my county public schools but appear to receive the greatest amount of pushback by student health services. Two of my children have asthma, I have never been told that their medical orders would have to be changed or adjusted before the school could provide care. But every year, for almost 5 school years, my T1D child's orders have been rewritten to appease what the county student health services wants. For all of these reasons I ask you to vote Yes!

Say No to SB1303

Dear Representative, I am writing to express my strong opposition to SB1303 which would change the care of students with Diabetes in the school setting. As a school nurse, I was disheartened when I read the bill as no stakeholder other than parent advocates vetted this bill and no other steak holders are in support. Language in the bill requires nurses and unlicensed staff to insert/reinsert pumps and CGMs if they become dislodged or need changing during school hours. Diabetic plans (DMMP) at the schools provide for safely taking care of diabetic students using a backup method if a pump/CGM fails. The plan orders parents to provide a back vial of insulin and a glucometer and NOT nurses to reinsert. The existing law states nurses”may assist” students with reinsertion if they are trained and willing, however it is in NO WAY a mandate to do so. Many school systems in Virginia do not have Registered Nurses. Requiring such medical procedures and trying to keep up with technology for training, creates inequities across the state. It is already difficult to get enough unlicensed staff trained to care for diabetic students as they can refuse the training. This bill will not help the situation. What is the cost for school districts to retain a certified pump trainer, all the different pumps and CGMs and accompanying supplies, and continuing to update technology as it changes frequently? There are also concerning requirements in the bill regarding who and when a diabetic plan (DMMP) is signed. We often receive medical paperwork and need to reach out to the doctor for clarification. Requiring principals and unlicensed staff to staff also sign upon receipt is not appropriate. Principals are not necessarily trained to care for diabetic students. Unlicensed staff sign training documents annually once they have done all of the required reviews (including going over DMMPs) necessary to provide care to a diabetic student for the current school year. SB1303 places unethical inequities across the health conditions and removes my ability to triage events going on in the school system accordingly. All needs of the 246 diabetic students should not be placed above the needs of 507 students with cardiac disorders, 6,020 students with Asthma, 662 with seizure disorders, 9,082 with life threatening allergies,etc. All students in our care should feel safe in oour ability to respond as needed particularly in an emergency. Language in this bill suggests diabetic students’ needs always come first and sometimes they should not. The student having a seizure should not have to wait while routine insulin dosing for a meal occurs for a diabetic student for example. The VDOE, American Diabetes Association (ADA), Virginia Association of School Nurses (VASN), and Virginia Diabetes are all against the language in SB 1303. For changes this significant, all steakholders should be at the table. Attached is the pump training form from the American Diabetes Association. The pump training form lays out what we need to know/teach regarding using a pump. You will notice there is nothing about reinsertion as that skill is something that is not required or recommend by ADA, VDOE, or VA laws. VOTE NO on 1303. All steakholders should have vetted this bill. Leigh Ann Garrison. Dumfries, VA

VOTE NO ON SB 1303. I am a school nurse in Northern Virginia. My concerns are my own, and do not represent my school district. I am writing to express my strong opposition to Bill 1303, currently under consideration in the House, which would change the care of students with Diabetes in the school setting. Are you aware that stakeholders were not brought to the table to help craft this bill? The Virginia Association of School Nurses, the Virginia Diabetes Council and all of the over 100 nurses in Senator McPike's district including our leadership and Diabetes Resource Nurses were not invited to collaborate, nor made aware of this bill until it was introduced. Leaving stakeholders out is a very poor decision, when we are the ones in the schools daily and can provide insight into what care for diabetic students in schools really looks like. As a constituent of Senator McPike, I have reached out and received no response from him or his staff. As a school nurse, I was disheartened when I read the bill. Language in the bill requires nurses and unlicensed staff to insert/reinsert pumps and CGMs if they become dislodged or need changing during school hours. These device companies do not provide any type of training equipment to schools and the practice of teaching reinsertion in a school is not sustainable financially or in practice. The equipment is very expensive and new technology is coming out frequently. In addition Diabetic plans at the schools provide for safely taking care of diabetic students using a backup method if a pump/CGM fails. School nurses also do not reinsert other devices such as PICC lines or g-tubes if they become dislodged. These procedures are also not appropriate for a school setting. Many school systems in Virginia do not have Registered Nurses due to a failure to pass school nurses as a required part of the SOQ. Requiring such medical procedures and trying to keep up with technology for training, creates inequities across the state. It is already difficult to get enough unlicensed staff trained to care for diabetic students as they can refuse the training. This bill will not help the situation. There are also concerning requirements in the bill regarding who should sign, and when a diabetic plan (DMMP) is presented to the school. It makes no sense. Nurses often need to reach out to medical providers for clarification on orders before we sign and enact them. We do this for the protection of our students and staff. The DMMP is a six page document, and we make sure it is completed and clear before signing. We do not just blindly sign documents. There is language in the bill that DECREASES the amount of training to bus drivers as well as supports present for diabetic students during school sponsored events. We want to take care of diabetic students as well as all of our other students. We want to work with our parents of diabetic students, and collaborate with them to ensure care is delivered in a safe, equitable manner. This bill hinders that. If you have not done so, please reach out to the school division in the area that you represent and ask them what they think of this bill. The sentiment of strong opposition will be the same. All Stakeholders need to be invited to the tablePlease vote NO for SB 1303. Karen McKeown FNP-C, MN, RN