Nebraska schools use this Department of Education statement when a student's meal accommodation cannot be met within the federal school meal pattern requirements. The licensed professional describes the physical or mental impairment that restricts the diet, lists foods to omit and substitute, and notes any texture or thickness changes. The family returns it to the school, which logs the date received and any follow-up.
A state-licensed health care professional completes and signs the medical section; the form names physicians (MD or DO), physician assistants, APRN nurse practitioners, chiropractors and registered dietitians. The parent or guardian fills in the child, contact and school details, and the school completes its internal-use box.
Download the current version from the source each time; forms change without notice.
Medical Statement
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The form must be completed by a State Licensed Health Care Professional. It names physicians (MD or DO), physician assistants, APRN nurse practitioners, chiropractors and registered dietitians. The one exception is a milk accommodation at lunch only, where the child's parent or guardian may sign instead.
Only when the accommodation cannot be made within the federal meal pattern requirements for school meals. Changes that still meet the meal pattern go on the Request for Meal Accommodation, which a parent or guardian may complete without a clinician's signature.
Yes. The Nebraska Department of Education posts a Spanish Word version of the Medical Statement next to the English one on its special diets page. Both are editable .docx templates, so the clinician can type the impairment, foods to omit and substitute, and texture or thickness changes before signing.