Connecticut schools use this statement to make meal modifications for a child in any USDA school nutrition program, from lunch and breakfast to afterschool snacks, summer meals and the CACFP at-risk supper. The clinician explains how a physical or mental impairment restricts the diet and gives the diet plan, food omissions and substitutions, texture changes and equipment.
The parent or guardian completes and signs Section A, including a HIPAA and FERPA release naming the clinician and school district. The child's MD, DO, PA, APRN or registered dietitian completes and signs Section B, adding an office stamp if available.
Download the current version from the source each time; forms change without notice.
Medical Statement for Meal Modifications in the School Nutrition Programs
Declaración médica para la modificación de alimentos en los programas de nutrición escolar
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No. CSDE notes that the statement cannot require a specific diagnosis by name and cannot use the terms 'disabled' or 'disability.' Instead, describe how the physical or mental impairment restricts the child's diet and how to accommodate it, listing foods to omit and their alternatives.
Yes. CSDE posts a Spanish form, Declaración médica para la modificación de alimentos en los programas de nutrición escolar, along with Spanish instructions. Both versions use the same Section A for the parent and Section B for the licensed professional or registered dietitian.