Texas schools in the National School Lunch and School Breakfast Programs need a signed medical statement before changing a student's meals for a disability or special dietary need. This Texas Department of Agriculture sample can serve as that statement or as a template for writing one. The parent returns it to the school, which plans omissions, substitutions or texture changes from what the clinician writes.
A medical authority licensed in Texas to write prescriptions, or a registered dietitian, completes sections I through III and signs section IV. The parent or guardian also signs section IV; for a fluid milk substitute at lunch only, the parent's signature alone is enough.
Enter the student's name, birthdate and grade level, then answer two yes/no questions: whether the student has a medical disability affecting a major life function that requires a meal accommodation, and whether the student has a special dietary need a meal accommodation would help. The answers tell the school whether the request falls under the disability rules that require an accommodation or is a special dietary need the school may choose to accommodate.
Explain the condition in enough detail for school food staff to understand how it restricts what the student can eat. TDA lists this explanation as the first required element of a medical statement. A diagnosis with no description of its effect on the diet leaves the school unable to act, or obliged to come back to you for clarification before serving a modified meal.
Check each accommodation that applies and give a detailed explanation in the box beside it: food items or ingredients not to be served, suggested substitutions, portion sizes, texture modifications for specific foods, special utensils, or other. When the student needs substitutions, list the foods or beverages that are appropriate replacements. A school does not have to serve a named brand if another product with the same specifications is available.
The parent signs and dates, and the medical authority or registered dietitian signs and dates. Both signatures are needed when the form is used as the medical statement. The only exception is a fluid milk substitute requested for lunch only, which needs just the parent's signature; milk changes at other meals and any other food change need the professional's signature.
The reverse side summarizes the rules. NSLP and SBP sites must make reasonable accommodations for students with a disability as defined in 7 CFR Part 15b. The statement must come from a medical authority licensed in Texas to write prescriptions or from a registered dietitian, and it must explain the dietary restriction and describe the accommodation. A school given an incomplete statement cannot make the accommodation, apart from lunch milk substitutes.
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Meal Accommodation for Disability Statement Sample Form
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A medical authority licensed by the State of Texas to write prescriptions, such as a physician, PA or APRN, or a registered dietitian. When the TDA sample form is used as the statement, both that professional and the parent or guardian sign it. A parent alone may sign only for a fluid milk substitute requested for lunch.
Not for lunch. For National School Lunch Program lunch service only, a written request from a parent or legal guardian can justify a nondairy fluid milk substitute for a disability. A milk substitution at breakfast or any other meal, or a change to any other food component, needs a licensed medical authority's or registered dietitian's signature.
The school must ask for clarification so it can serve a proper and safe meal. Any change to the medical statement has to be provided in writing before the school puts it in place, so a phone call alone does not update the student's accommodation.
No. TDA offers it either as the medical statement itself or as a guide for writing one. Whatever format you use, it must explain how the condition restricts the student's diet and describe the accommodation: foods or ingredients to omit, substitutes, texture changes or other needs.