Wisconsin schools use this Department of Public Instruction statement when a child's disability requires a change to school meals. Federal rules at 7 CFR Part 15b require the modification when a state authorized medical authority or registered dietitian supports the request in writing. The signer explains how the impairment restricts the diet, which foods to omit and which to substitute, and adds any comments.
A state authorized medical authority (physician, dentist, optometrist, podiatrist, physician assistant or nurse practitioner) or a registered dietitian completes section II and signs. The parent or legal guardian completes the student information and signs as well.
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Medical Statement for Special Dietary Needs
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A state authorized medical authority, which in Wisconsin means a physician, dentist, optometrist, podiatrist, physician assistant or nurse practitioner, or a registered dietitian. The form's title checkboxes list exactly these signers, and the parent or legal guardian also signs.
Not if the IEP or 504 plan already contains the information a medical statement requires: how the impairment restricts the diet, the foods to avoid and the foods to substitute. If the plan lacks any of these, the school will need a signed statement.
Yes. DPI posts fillable versions of the Medical Statement for Special Dietary Needs in English, Spanish and Hmong on its special dietary needs page, along with a policy template school food authorities use to tell families how to request a modification.