DIET ORDER
Medical Request for Students with Special Nutritional Needs
Child Nutrition Services – St. Lucie Public Schools
4204 Okeechobee Road, Ft. Pierce, FL 34947 Phone: (772) 429-6225
Part I: (To be filled out completely by parent or guardian).
Date: _______________ Student Name: ________________________________________________________
School: ___________________________________________ Email: __________________________________
Parent Name: ______________________________________ Phone: _________________________________
Part II: (To be filled out only by Licensed Physician).
1. Does the student have a disability (as defined under section 504 of the Rehabilitation Act Part B of IDEA) and
require a special meal accommodation (i.e. food allergy that results in anaphylaxis)?
Yes ______ No ______
If yes, please list the student’s disability, why the disability restricts diet and the major life activities affected by
the disability.
____________________________________________________________________________________________
____________________________________________________________________________________________
If the student is not disabled, please list the medical condition that requires a special meal accommodation.
(A licensed Physician, Nurse Practitioner, PA or RD must complete/sign this section).
___________________________________________________________________________________________
2. Diet Prescription: Please refer to school menu for acceptable substitutions when possible. Please list
foods/beverages to be omitted from diet and acceptable substitutions below. If necessary, attach additional
items and instructions on separate sheet.
Foods/Beverages to omit
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Specific Foods/Beverages to be substituted
_____________________________________
______________________________________
______________________________________
______________________________________
______________________________________
3. Texture Modification: (please select one)
a. Dysphagia Pureed (pudding like texture)
c. Dysphagia Advanced (moist, fork tender, chopped meats)
b. Dysphagia Mechanically Altered (ground or minced)
d. No texture modification needed
Part III:
I certify that the above named student needs special
school meals prepared as described above because of
the student’s disability or chronic medical condition.
_____________________________________________
Signature of Approved Medical Authority
Medical Office Stamp:
_______________
__________
Telephone number
Date
I hereby give permission for the school staff to follow the above stated nutrition plan.
__________________________________________________
Signature of Parent
___________________
Date
NON-DISCRIMINATION: In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director,
Office of Adjudication, 1400 Independence Ave, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are
hearing impaired or have speech dis-abilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136
(Spanish). USDA is an equal opportunity provider and employer.
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FOS0016
Physician’s Statement for Children with Disabilities
USDA regulations 7 CFR Part 15b require substitutions or modifications in school meals for children whose
disabilities restrict their diets. When food allergies result in severe, life threatening (anaphylactic) reactions, the
child’s condition would meet the definition of “disability”. A child with a disability must be provided substitutions
in foods when that need is supported by a statement signed by a licensed physician. The physician’s statement
must identify:
• The child’s disability;
• An explanation of why the disability restricts the child’s diet;
• The major life activity affected by the disability;
• The food(s) to omitted from the child’s diet, and the food or choice of foods that must be substituted;
• Specific substitutions needed must be specified in a statement signed by a licensed physician.
Menu Modifications for Children with Disabilities
Children with disabilities who require changes to the basic meal are required to provide documentation with
accompanying instructions form a licensed physician. This is required to ensure that the modified meal is
reimbursable, and to ensure that any meal modifications meet the nutrition standards which are medically
appropriate for the child.
Serving the Special Dietary Needs of Children Without Disabilities
Children without disabilities, but with special dietary needs requiring food substitutions or modifications, may
request that the school food service meet their special nutrition needs.
• The School Food Authority will decide these situations on a case-by-case basis. Documentation with
accompanying information must be provided by a recognized medical authority.
• While School Food Authorities are encouraged to consult with recognized medical authorities, where
appropriate, schools are not required to make modifications to meals based on food choices of a family
or child regarding a healthful diet. This provision covers those children who have food intolerances or
allergies but do not have life-threatening reactions (anaphylactic reactions) when exposed to the food(s)
to which they are allergic.
Instructions: (Incomplete forms will be returned for clarification).
Part I is to be filled out by parent or legal guardian.
Date – the date the form is being completed by the physician
Student Name – child’s full legal name (no nicknames please)
School – list school child currently attends
Parent’s Name – full name of parent or guardian
Phone number – please list number where parent or guardian may be contacted (home/cell/work)
Part II is to be completed by a licensed physician
1. The physician will check if the student has a disability that requires dietary modification and will list the
clinical diagnosis, why the disability restricts the student’s diet and the major life activity affected by the
disability.
2.
The physician will list all foods/beverages from the school lunch menu to be omitted from the student’s diet
and foods from the school lunch menu that are acceptable substitutions for the student to consume. The
school lunch menu is available at www.stlucieschools.org
3.
If the student requires texture modification the physician will indicate the required consistency/texture for
school meals.
Part III: The physician will sign; provide office telephone number, date of office visit and office stamp in the
indicated area.
Parent/guardian will sign and date the form providing permission for school staff to follow prescribed diet order.
Please return completed form to: St. Lucie Public Schools – Child Nutrition Services, 4204 Okeechobee Road, Ft. Pierce, FL 34947
Attention: Jennifer Muzzin. Please allow 10 days for meal accommodation to be made.