Form Cnp-925 - Medical Statement To Request Special Meals And Or Accommodations
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1
2California Department of Education
Child Nutrition Programs
Nutrition Services Division
CNP-925 (Rev. 06/14)
MEDICAL STATEMENT TO REQUEST
SPECIAL MEALS AND/OR ACCOMMODATIONS
1. School/Agency Name
2. Site Name
3. Site Telephone Number
4. Name of Participant
5. Age or Date of Birth
6. Name of Parent or Guardian
7. Telephone Number
8. Check One:
Participant has a disability or a medical condition and requires a special meal or accommodation. (Refer to
definitions on reverse side of this form.) Schools and agencies participating in federal nutrition programs
must comply with requests for special meals and any adaptive equipment. A licensed physician must sign
this form.
Participant does not have a disability, but is requesting a special meal or accommodation due to food
intolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schools
and agencies participating in federal nutrition programs are encouraged to accommodate reasonable
requests. A licensed physician, physician’s assistant, or nurse practitioner must sign this form.
9. Disability or medical condition requiring a special meal or accommodation:
10. If participant has a disability, provide a brief description of participant’s major life activity affected by the disability:
11. Diet prescription and/or accommodation: (Please describe in detail to ensure proper implementation-use extra pages as needed)
12. Indicate texture:
Regular
Chopped
Ground
Pureed
13. Foods to be omitted and substitutions: (Please list specific foods to be omitted and suggested substitutions. You may attach a
sheet with additional information as needed)
A. Foods To Be Omitted
B. Suggested Substitutions
14. Adaptive Equipment:
15. Signature of Preparer*
16. Printed Name
17. Telephone Number
18. Date
19. Signature of Medical Authority*
20. Printed Name
21. Telephone Number
22. Date
Physician’s signature is required for participants with a disability. For participants without a disability, a licensed
*
physician, physician’s assistant, or nurse practitioner must sign the form.
The information on this form should be updated to reflect the current medical and/or nutritional needs of the participant.
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for
employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and
where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an
individual’s income is derived from any public assistance program, or protected genetic information in employment or
in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs
and/or employment activities.)
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