Special Dietary Needs Form
Complete and submit this form to Family Development Services. The parent/guardian/adult participant will complete part 1 and 2, and the physician or medical authority (physician's assistant or nurse practitioner) will complete part 3. Refer to the information below for clarification. Attach a sheet with additional information if necessary. If changes are needed, the parent/guardian/adult participant is required to submit a new form.
Disability: USDA requires substitutions or modifications in CACFP meals for participants whose disabilities restrict their diets. The definition of the term "disability" has broadened and nearly all physical and mental impairments constitute a disability.
Section 504 of the Rehabilitation Act, the Americans with Disabilities Act, and Departmental Regulations at 7 CFR Part 15b define a person with a disability as any person who has a physical or mental impairment which substantially limits one or more "major life activities," has a record of such impairment, or is regarded as having such impairment. (See 29 USC § 705(9)(b); 42 USC § 12101; and 7 CFR 15b.3.) "Major life activities are broadly defined and include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working, "Major life activities" also include the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. (See 29 USC § 705(9)(b) and 42 USC § 12101.)
A physical or mental impairment does not need to be life-threatening to constitute a disability. It is enough that the impairment limits a major life activity. Further, an impairment may be covered as a disability even if medication, or another mitigating measure, may reduce the impact of the impairment.
Forms or medical statements for disabilities must be signed by a licensed physician, physician's assistant, or nurse practitioner and must identify the child's medical condition; an explanation of why the disability restricts the child's diet; the major life activity affected by the disability; the food or foods to be omitted from the child's diet, and the food or choice of foods that must be substituted.
Special Dietary Needs That Are Not a Medical Condition: Food service may make food substitutions, at their discretion, for individual children who do not have a disability/medical condition, but who have special dietary needs for other reasons such as religious, cultural, or other preferences. CACFP participating organizations are encouraged to accommodate reasonable requests but are not required to do so. For these requests, the form may be signed by a parent/guardian/adult participant.
The form should include an identification of the special dietary need that restricts the diet; the food or foods to be omitted; and the food or choice of foods to be substituted.
To be completed by a Parent, Guardian, or Authorized Representative
Child's Name (Required)
Parent, Guardian, or Authorized Representative (Required)
(Required) Part 2 Describe the participant's special dietary need: (Required) Foods to be omitted: (Required) Please list additional information regarding the diet: (Required) Parent/Guardian/Adult Participant/rep. of Adult Participant Signature (Required)
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**If this is a Food Allergy – a Food Allergy Action Plan is required to be completed in addition to this form.**
Describe the patient's medical condition and the major life activities that are affected: Please list additional information regarding the diet (including texture changes such as chopped, ground, pureed, etc.): Licensed physician, physician's assistant or nurse practitioner signature
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