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NC DPI Medical Statement for Unique Mealtime Needs

North Carolina schools cannot change food textures, substitute foods or alter a student's diet without documentation from a healthcare professional, and this statement provides it. Fully completed, it gives the school what USDA, the Office for Civil Rights and OSERS require. The clinician describes the impairment and how it restricts the diet, then lists omissions, substitutions and consistencies.

Who completes it

The parent completes Part A. A state-licensed healthcare professional (MD, NP or PA) or registered dietitian nutritionist completes and signs Part B, and the school nutrition administrator and IEP or 504 coordinator sign Part C.

Submitting and payment

How to submit it
The parent returns the fully completed statement, signed by both the parent and the healthcare professional, to the school as the district's procedures specify.

Good to know

  • For food allergies, say whether it's an intolerance, an allergy affecting school participation, or life-threatening. Life-threatening allergies need an emergency action plan at school.
  • Food consistency options are pureed, mechanical soft, ground or chopped. Liquids can be clear or full liquid, or nectar-, honey- or pudding-thick.
  • Attach previous feeding or nutrition evaluations and care plans. If your assessment can't support a determination, refer the family to the appropriate professional.
  • DPI asks providers to consider being available to the student's mealtime planning team, which may include the parent, the school nutrition administrator and therapists.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Statement for Students with Unique Mealtime Needs for School Meals

Official pagePDF

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Frequently asked questions

Who can sign North Carolina's Medical Statement for Unique Mealtime Needs?

Part B is completed by a state-licensed healthcare professional, such as a pediatrician or family doctor (MD), nurse practitioner or physician assistant, or by a registered dietitian nutritionist. DPI also links USDA memo SP 07-2025 on accepting medical statements from registered dietitians.

What happens after the NC school receives the medical statement?

The school nutrition administrator and the 504 coordinator or IEP representative sign Part C to show it was received and reviewed and that a plan is being developed. Parents are encouraged to ask when the team will meet and may invite community providers who know the child's feeding needs.