Medical Statement to Request Special Meals, Accommodations, Milk Substitutions
1. Site Name (School/Sponsor): 2. Name of Child * 3. Age or Grade  
4. Name of Parent or Guardian 5. Telephone Number  
6. State the medical condition requiring accommodation:  
This section must be completed bya licensed medical authorityRefer to the reverse side of this page for definitions.
    7. Does the medical condition affect major life activities or major bodily functions? Select one of the following. *
           □  Yes, this condition affects major life activities or major bodily functions and qualifies as a disability
            □  No, this condition does not  affect major life activities or major bodily functions and does not qualify as a disability
     According to the ADA the term 'disability' means, with regards to an individual: a physical or mental impairment that substantially limits one or
'     more major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment. The USDA has adopted this definition of a      
      disability in child nutrition  programs.
 
8. Provide a brief description of the major life activity or bodily function affected by the disability. *
Consuming foods to be omitted may result in:
      0    Nausea    □ Vomiting   D  Diarrhea   Itching  Swelling   0    Rash    0    Wheezing/Coughing   D  Choking
      □ Other:
 
   9. Describe diet prescription and/or accommodation. Must include specific foods to be omitted and substituted. *  
Foods and/or beverages to be omitted: * Foods and/or beverages to be substituted: *  
10.  Modified texture (if applicable):        □ Chopped       □ Ground      □ Puree  
11. Adaptive Equipment Needed (if applicable):
12. Signature of Medical Authority Credentials*     13. Printed Name*                                       14. Telephone Number         1  1S. Date*
 
       
I give permission for the  institution's personnel responsible for  implementing my child's prescribed diet order to discuss my child's special dietary accommodations with any appropriate institution staff and to follow the prescribed diet order for my child's meals. I also give permission for my child's medical authority to further clarify the prescribed diet order on this form if requested to  do so by institution personnel.
Signature of parent or guardian:                                                -                                 Date:
 
*Required
Medical Statement to Request Special Meals, Accommodations, Milk Substitutions
A licensed medical authority is defined as an individual who has the  authority to write a medical prescription. In Utah, this includes:
•      M edicaDoctor  (MD)                                                    •       ,l\d  anr.e practice   Registe:ed r..rurses{APRN)
•       Physi cian's Assistan(PA)
•       OsteopathiPhysic ians (DO)
•       Naturop.;;ttiic Ph.ysiciam (ND c-rNMD)  I
Who can complete this form?  
For substitutions due to disability
•    The accommodation  request must be followed by the inst it ution.
For substitutions NOT due to a disability
•    The school/sponsor may choose to  accommodate the request or not.
 
Licensed medical authority (see above) Licensed medica authority (see above) Regist ered Nurse (RN)
Register ed Dietitian (RD/RDN)
Parent or Guardian (Must meet meal pattern to be claimed)
 

Definition of Disability
Under Section 504 of the Rehabilitation Act of 1073 and the Americans with Disabilities Act (ADA) A Person with a Disability is defined as: any person who has a physical or mental Impairment which substantially limits one or more major life act ivities, has a record of such impairment, or is regarded as having such an impairment.
Physical or Mental lmpairment-(a) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss
affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive, digestive, genitor-urinary; hemic and lymphatic; skin; and endocrine; or
(b) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities.
Major Life Activities -functions  such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking,
breathing, learning, and working.
Major Bodily Functionsfunctions of the immune system, normal cell growth, digestive, bowel, blad der, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, and reproductive functions
Record of Impairment-having a history of or have been classified (or misclassified) as having a mental or physical impairment that substantially limits one or more major life activ ities. Individua  s who take mitigating measures to improve or control any of the conditions recognized as a disability, are still considered to have a disability and require an accommodation.
USDA Guidelines for Accommodating Special Dietary Needs
Disabili t y-Institutions  and agencies participating in federal nutrition programs mustcomply with requests for special dietary meals and any adaptive equipment with a documented disability and completed request form.
Non-disability-Institutions and agencies participating in federal nutrition programs maycomply with requests for non-disabling medical conditions. Accommodat  ons will be made on a case-by-casebasis. However, if accommodations are made for a specific medical condition, complete requests for the same medical condition for other participants must be accommodated.
Fluid Milk Substitutions-Fluid milk substitutions apply to non-disability  requests. Institutions and agencies participating in the federal nutrition program mayaccommodate complete requests with a USDA approved non-milk equivalent. If accommodations are made for one child requesting a fluid milk substitute, accommodations must be made for all children
requesting a fluid milk substitute.
 
School/sponsor internal use only    
□  Marked as disab ility  or treating as disability (required  to accommodate request)
□  Not marked as disability
□  School/sponsor is accommodating request
□  School/sponsor is not  accommodating request
   
Signature/Date:    
             
             

pdfMedical_statement.pdf

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