Colorado schools and agencies in USDA child nutrition programs use this statement to accommodate a child's documented disability or medical need at no extra charge. The prescriber explains the need, the major life activity affected, the diet type, texture and liquid levels, equipment, and foods to omit and substitute, and the school implements that order.
A parent or school contact fills in Part A. A licensed physician (MD or DO), advanced practice nurse with prescriptive authority, PA or registered dietitian completes and signs Part B, and the parent signs a permission letting staff discuss and clarify the diet order.
Download the current version from the source each time; forms change without notice.
Medical Statement for Meal Modification
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The form accepts a licensed physician (MD or DO), an advanced practice nurse with prescriptive authority, a physician assistant or a registered dietitian. The signer adds title, printed name, phone and date, and the parent's permission lets that professional clarify the diet order if school staff ask.
Not automatically. The form says meal modifications continue until a request to change or stop them is made on the Discontinuation Form, which the school or site provides. CDE strongly recommends that the prescribed diet order be updated every year with a new form.
Yes. CDE posts English and Spanish versions of the Medical Statement for Meal Modification, along with a Dietary Preference Form for non-medical requests, a Discontinuation Form, a letter to parents and a Fluid Milk Disability Parent Request Form.