Medical Plan Of Care For School Food Service

ADVERTISEMENT

Medical Plan of Care for School Food Service
(Students with Disabilities and Non-Disabling Special Dietary Needs)
The following child is a participant in one of the United States Department of Agriculture (USDA) school nutrition programs.
USDA regulations 7CFR Part 15B require substitutions or modifications in school program meals for children whose
disability restricts their diet and is supported by a statement signed by a licensed physician. Food allergies which may
result in a severe, life-threatening (anaphylactic) reaction may meet the definition of “disability.”
The school may choose to accommodate a student with a non-disabling special dietary need that is supported by a
statement signed by a recognized medical authority (physician, physician assistant or nurse practitioner).
The school food authority may choose to make a milk substitution available for students with a non-disabling special
dietary need, such as milk intolerance or for cultural or religious beliefs. If the school food authority makes these
substitutions available, the milk substitute must meet nutrient standards identified in regulations. If available, this will be
indicated in Part 2. A parent/guardian or recognized medical authority (physician, physician assistant, or nurse
practitioner) may complete this section. If this is the only substitution being requested, complete Part 1 and 2 only.
Part 1: To be completed by Parent/Guardian (all requests for special dietary needs)
Child’s Name
Date of Birth
M
F
Name of School/Center/Program
Grade Level/Classroom
Parent’s/Guardian’s Name
Address, City, State, Zip Code
([
])
([
])
Home Phone
Work Phone
Part 2: Request for milk substitution for non-disabling special dietary needs only
School/school district does not make milk substitutes available to students with non-disabling special dietary needs. Do not
complete Part 2.
School/school district provides __________________________________ as a milk substitute to students with non-disabling
or other special dietary needs when Part 2 is completed by Medical Authority or Parent/Guardian and approved by the
school/school district.
Does the child have a non-disabling medical or special dietary need that restricts intake of fluid milk?
Yes
No
List medical or special dietary need (e.g., lactose intolerance or for cultural or religious beliefs):
Medical Authority or Parent/Guardian Signature:__________________________________________ Date:_____________
Part 3: To be completed by Physician/Medical Authority
Disability/Special Dietary Needs
Does the child have a disability?
Yes
No
If Yes,
Please describe the major life activities affected by the disability.
Does the child’s disability affect their nutritional or feeding needs?
Yes
No
If the child does not have a disability*, does the child have special nutritional or feeding needs?
Yes
No
(*These accommodations are optional for schools to make)
If the child has a disability or special dietary/feeding need, please complete Part 4 of this form and have it signed and
stamped with the office name and address of a licensed physician/recognized medical authority.
Part 4: To be completed by Physician/Medical Authority
Diet Order
List any dietary restrictions, such as food allergies, intolerances or restrictions:
Special Dietary Needs
January 2010

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2