Hawaii's school, child care and summer meal programs use this statement to modify meals for a student whose physical or mental impairment restricts the diet. Fully completed, it gives the program the information USDA and the Office for Civil Rights require. The clinician describes the impairment, major life activities affected, foods to omit and substitute, and texture or liquid changes.
The parent or guardian completes and signs Part A. A recognized medical authority completes and signs Part B, and program administrators or the IEP or 504 coordinator complete Part C.
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HCNP Medical Statement for Students with Unique Mealtime Needs
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The form says that if your assessment doesn't give enough information to complete the sections that apply to the student's mealtime needs, refer the child and family to the appropriate health care professional to finish the assessment. A separate care plan can be attached instead of listing every food on the form.
Part A lets the parent select School Breakfast, National School Lunch, Afterschool Snack, Fresh Fruit and Vegetable, the Child and Adult Care Food Program and the Summer Food Service Program. One statement can therefore support meal changes across every program the student uses.