Title Page
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Document No.
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Conducted on
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Employee Name
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Client / Site
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Location
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How long has the member of staff had Type 1 diabetes?
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Has their symptoms become more severe in recent weeks or months?
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Do they require daily blood glucose checks?
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Do they require insulin injections?
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Do they require a sharps disposal bin? (if yes, they should be able to obtain one from their GPs / Pharmacist)
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Please insert instructions should employee suffer a Hypoglycaemia (Hypo) including where medication or food that is required, is kept
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Any other information we need to be aware of
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Signed Member of Staff
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Signed Risk Manager
