MEDICAL STATEMENT TO REQUEST

SPECIAL MEALS AND/OR ACCOMMODATIONS

1.  School or Agency		2.  Site Name				3. Site Phone Number
4. Name of Child or Participant						5. Age or Date of Birth
6. Name of Parent or Guardian						7. Phone Number
8. Description of Child or Participant’s Physical or Mental Impairment Affected:
9. Explanation of Diet Prescription and/or Accommodation to Ensure Proper Implementation:
10. Indicate Food Texture for Above Child or Participant:    Regular                     Chopped                     Ground                    Pureed
11.  Foods to be Omitted and Appropriate Substitutions:   Foods To Be Omitted                                                    Suggested Substitutions
12. Adaptive Equipment to be Used:
13. Signature of State Licensed Healthcare Professional*		14. Printed Name			15. Phone Number		16. Date

 

*For this purpose, a state licensed healthcare professional in California is a licensed physician, a physician assistant, or a nurse practitioner. 

The information on this form is required to reflect the current medical and/or nutritional needs of the child.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.  Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW Washington, D.C. 20250-9410; fax: (202) 690-7442; or email: program.intake@usda.gov. This institution is an equal opportunity provider.

 

Instructions

1.     School/Agency: Print the name of the school or agency that is providing the form to the parent.

2.     Site: Print the name of the site where meals will be served.

3.     Site Phone Number: Print the phone number of site where meal will be served.

4.     Name of Child/Participant: Print the name of the child/participant to whom the information pertains.

5.     Age of Child/Participant: Print the age of the child/participant. For infants, please use date of birth.

6.     Name of Parent/Guardian: Print the name of the person requesting the child/participant’s medical statement.

7.     Phone Number: Print the phone number of parent/guardian.

8.     Description of Child/Participant’s Physical or Mental Impairment Affected: Describe how the physical or mental impairment restricts the child/participant’s diet.

9.     Explanation of Diet Prescription and/or Accommodation to Ensure Proper Implementation: Describe a specific diet or accommodation that has been prescribed by the state healthcare professional.

10.   Indicate Texture: If the child/participant does not need any modification, check “Regular”.

11.   Foods to be Omitted: List specific foods that must be omitted (e.g., exclude fluid milk).

Suggested Substitutions: List specific foods to include in the diet (e.g., calcium-fortified juice).

12.   Adaptive Equipment to be Used: Describe specific equipment required to assist the child/participant with dining (e.g., sippy cup, large handled spoon, wheel-chair accessible furniture, etc.).

13.   Signature of State Licensed Healthcare Professional: Signature of state licensed healthcare professional requesting the special meal or accommodation.

14.   Printed Name: Print name of state licensed healthcare professional.

15.   Phone Number: Phone number of state licensed healthcare professional.

16.   Date: Date state licensed healthcare professional signed form.

Definition

Disability means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment.

Physical or mental impairment means, any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more body systems, such as: neurological, musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, immune, circulatory, hemic, lymphatic, skin, and endocrine; or any mental or psychological disorder such as intellectual disability, organic brain syndrome, emotional or mental illness, and specific learning disability.

Physical or mental impairment includes, but is not limited to, contagious and noncontagious diseases and conditions such as the following: orthopedic, visual, speech, and hearing impairments, and cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disability, emotional illness, dyslexia and other specific learning disabilities, Attention Deficit Hyperactivity Disorder, Human Immunodeficiency Virus infection (whether symptomatic or asymptomatic), tuberculosis, drug addiction, and alcoholism.

Major life activities include, but are not limited to caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, writing, communicating, interacting with others, and working; and the operation of a major bodily function.

Major bodily function includes, the operation and functions of the immune system, special sense organs and skin, normal cell growth, and digestive, genitourinary, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and reproductive systems. The operation of a major bodily function includes the operation of an individual organ within a body system