Washington schools and child nutrition sites use this one-page OSPI request when a child with a disability needs a meal modification. The parent fills in the student and site details and signs; the medical authority completes the diet order, describing how the food affects the child, what must be omitted or avoided, and what to substitute, provide or modify. The current version is dated March 2026.
A state-recognized medical authority (MD, DO, PA with prescriptive authority, naturopathic physician or ARNP) completes and signs the diet order; for school meals and CACFP, a registered dietitian's statement may also be accepted. The parent or guardian completes and signs the top section.
Download the current version from the source each time; forms change without notice.
Request for Special Dietary Accommodations
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A State-Recognized Medical Authority, meaning a licensed provider who can write prescriptions in Washington: an MD, DO, physician assistant with prescriptive authority, naturopathic physician or ARNP. Under the school lunch and breakfast programs and CACFP, a statement signed by a registered dietitian may also be accepted.
Three items: how the impairment affects the child, such as how eating or touching the food affects them; what must be done to accommodate the diet, including specific foods to omit or avoid; and the foods or beverages to substitute, provide or modify. Then sign, date and add the clinic name.
Yes. OSPI posts the Request for Special Dietary Accommodations in Spanish, Chinese, Marshallese, Russian, Somali and Vietnamese, along with English, on its National School Lunch Program requirements and materials page.