Exhibit V - Blood Sugar Log.pdf

PDF 126 KB Posted Jun 1, 2024

Attached to: Master Agreement AZ|CTR071431
Contract number: CTR071431
Issued by: Arizona

About this file

Written by GovTribe AI · Sep 19, 2025

This document is a Congregate Care Blood Sugar Log form issued by the Arizona Department of Child Safety, designated as Exhibit V with a date of 05/24. The form is designed for tracking blood sugar measurements and medication administration for clients in congregate care settings.

The log provides a comprehensive grid for recording daily blood sugar readings, including columns for time, client and staff initials, blood sugar levels, and comments. The form includes sections for documenting medication details such as dosage, purpose, and special instructions, as well as spaces to record the client's name, date of birth, physician's information, and medication evaluation details. Additional tracking elements include checkboxes for refill availability, travel bottle status, and management verification, allowing for systematic monitoring of a client's diabetes management and medication regimen.

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CONGREGATE CARE

BLOOD SUGAR LOG

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit V (05/24)

Print Name Signature

Client

Staff

Client’s Name Date of Birth

Month

Physician’s Name Physician’s Phone No.

Year

Medication Dosage

Purpose of Medication Time of Dosage

DayDay TimeTime Client Client InitialInitial

Staff Staff InitialInitial Blood SugarBlood Sugar TimeTime Client Client

InitialInitial Staff Staff InitialInitial Blood SugarBlood Sugar Comments (e.g., snack given, nurse line, medical attention, refused treatment)Comments (e.g., snack given, nurse line, medical attention, refused treatment)

Special Instructions:

Medication Instructions:

CONGREGATE CARE

BLOOD SUGAR LOG

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit V (05/24)

Month Year

DayDay TimeTime Client Client InitialInitial

Staff Staff InitialInitial Blood SugarBlood Sugar TimeTime Client Client

Date to Order Refill Next Med Evaluation Refill Bottle Count (prior to starting the bottle) Refill Started Date (only to be filled out when a refill bottle starts)

Strip Count Yes No Yes No

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File details come from the government source that posted it. Updated Sep 19, 2025.