Child Nutrition Department

Diet Prescription for Meals at School

131 Guthrie • San Antonio, Texas78237

Telephone (210) 444-7975 Fax (210) 444-7998

FS160 (Rev. May 2011) School Year 2016-2017

Student’s Legal Name: / Date of Birth:
Student ID: / School Attending: / Grade (Sept. 2016):
Date of Admissions, Review, & Dismissal (ARD) Meeting/Section 504 meeting:
(Parents – please include an FCNS nutrition professional in the ARD/504 meeting at the school at least 1x/year.)
Parents: please read these instructions carefully - This required form is to be used by medicalprofessionals to indicate whether a special diet or food modification is warranted for an EISD student. A new form is required yearly. Special diet requests will be reviewed and evaluated on a case-by-case basis by the Child Nutrition Director as per Federal/State requirements. The Director will make every attempt to reasonably accommodate students that have dietary restrictions that are not life threatening or reported by a physician as a disability.
In the case of milk or lactose intolerance, a lactose free milk or USDA approved soy milk will be given as an option. Fruit juice or water can no longer be substituted in some meals (please see the “Use of Non-Dairy Substitute Statement” attached to this packet).
The statement of disability must include:
• The nature of the disability and the reason the disability prevents the child from eating the regular
school meal.
• The major life activity affected by the disability. Under Section 504 of the Rehabilitation Act of 1973, the
Americans w/ Disabilities Act (ADA), and the ADA Amendments Act of 2008, a “person with a disability”
is any person who has a physical or mental impairment that substantially limits one or more major life
activities, has a record of such an impairment or is regarded as having such an impairment.
• Must list the specific food(s) to be omitted from the child’s diet.
To be Completed by a Licensed Physician only
1. Condition/Diagnosis that requires a special diet or food modification at school:
2. Does this student have a disability? / Yes / No
3. If yes, describe the major life activities that are affected by the disability:
4. Please specify the diet order (See back for additional guidance)
Licensed Physician (Print): / Date:
Licensed Physician Signature: / Phone:
Registered Dietitian working w/case: / Phone:
Page 2 continued – Name of Student:
MILK/LACTOSE INTOLERANCE: / Yes / No / NA / (see the Use of Non-Dairy Substitute statement)
Can be completed by a Licensed Medical Authority (Physician’s Assistant, Nurse Practitioner or Medical Physician)
Signature – Medical Authority / Office Phone Number / Date
MUST BE COMPLETED BY A LICENSED PHYSICIAN – MARK ONLY THOSE THAT APPLY TO THIS STUDENT
A. TEXTURE MODIFICATION: / Chopped/bite size pieces / Finely ground / Pureed / Soft
B. NUTRITION SUPPLEMENT REQUIRED – Formula name
To be administered (specify time & quantity)
C. FOOD ALLERGIES – submit an allergy profile if possible
Peanut/Tree Nut allergy
Milk/Dairy allergy (NOT LACTOSE INTOLERANCE)
Milk/Dairy allergy (NOT LACTOSE INTOLERANCE) including cheese and products made with dairy such as milk in baked products or entrées
Wheat (most of CND food items contain wheat – parent is encouraged to (1) select menu items the student may consume by circling the items and (2) submit menu selections to Child Nutrition Director)
Soy (most CND food items contain soy-parent is encouraged to (1) select menu items the student may consume by circling the item and (2) submit menu selections to Child Nutrition Director)
Whole Egg
Egg products in food (such as in baked items, entrées, mayonnaise), etc.
Fish
Other
PARENT/GUARDIAN:
Some substitutions may not be available or allowed. A meeting with the Child Nutrition Director may be needed for additional clarification. Under no circumstances are Child Nutrition Department Staff allowed to revise or change a diet prescription or medical order. A copy of the menu is available at the schools and online (
I understand that if my child’s medical or health needs change, it is my responsibility to notify the school office and also have the physician complete a new Diet Prescription for Meals at School form.
Parent/Guardian’s Signature / Date / Home Phone Number
Parent/Guardian’s Printed Name / Parent/Guardian’s Email Address
FOR EISD CND ONLY
Date Received: / ARD/504 Meeting:
Reviewed by:
Comments:
Nondiscrimination Statement: In accordance with Federal Law and the 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 Avenue, SW, Washington, D.C.20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities 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

Revised May 2011