Medical Statement Form

Medical Statement Form

Where will the Medical Statement form be "housed" in CHCCS?  

The school based nurse will keep the Medical Statement form and disseminate copies to the appropriate school based staff. 

What if there is no Medical Statement yet it is evident he/she may have special dietary needs?

Schools are required by Federal law to implement “Child Find” which requires that students with
suspected disabilities are identified, located, and evaluated. The Dietary Modification Decision‐making
Flowchart can provide guidance for this process for students who require dietary modification. Schools
have a reasonable length of time to assemble a team to assess student needs and formulate an
appropriate accommodation plan such as a 504 Accommodation Plan or an Individualized Education
Program (IEP). Based on a review of the available literature, best practice standards suggest up to ten
days is sufficient to assess student needs and develop a plan of action. Parents are an excellent source of
information regarding foods the student ate prior to being enrolled in school. Parents must be involved
and may have to provide food until the school can make appropriate accommodations.

Most schools would initially defer to the Individuals with Disabilities Education Act (IDEA) and use those
Federal funds for an evaluation to determine if the student is eligible for disability services. If not eligible
for an IEP, the student may qualify for Section 504 of the Rehabilitation Act of 1973 accommodations.
Dietary needs may be identified in either an IEP or a 504 Accommodation Plan. For any dietary
modification, a completed and signed Medical Statement must be secured. For students with a
disability, the Medical Statement must be signed by a licensed physician. For students without a
disability, the Medical Statement must be signed by the licensed physician or a recognized medical
authority, which includes a physician assistant or nurse practitioner.

References:

Child Find, Office of Special Education Programs, U.S. Department of Education
www.childfindidea.org
Dietary Modification Decision‐making Flowchart, Special Diet, Child Nutrition Services, N.C. Department of Public
Instruction
http://dpi.state.nc.us/childnutrition/publications/special‐diet/
Individuals with Disabilities Education Act (IDEA), U.S. Department of Education
http://idea.ed.gov/
Section 504 of the Rehabilitation Act of 1973, U.S. Department of Education
www2.ed.gov/about/offices/list/ocr/504faq.html
Office of Civil Rights Decisions, Seattle, Washington Public Schools (31 IDELR 193), Individuals with Disabilities
Education Law Report
http://web.diabetes.org/Advocacy/legalmaterials/LegalRights/LR‐Chap7.pdf

What should school personnel do if told by a parent/guardian that a student needs a special dietary
accommodation and there was no Medical Statement available?

Schools should develop a clear procedure for handling these types of concerns. Schools are required by
Federal law to implement “Child Find” which requires that students with suspected disabilities are
identified, located, and evaluated. If a parent/guardian tells school personnel that a student needs a
modified diet, the school may have reason to suspect the existence of a disability. The school is then
responsible for evaluating the student and determining eligibility. 

An evaluation for a feeding or nutritional problem is initiated by the Medical Statement for Students with Special Nutritional Needs for School Meals, which is an essential part of the data required to determine if
the student requiring dietary modifications has a disability. The Medical Statement should be provided to
the parent or guardian. Dietary accommodations for students with a disability must be prescribed by a
licensed physician. The Medical Statement must be completed and signed by both the parent or guardian
and a licensed physician and returned to the school as directed at the top of the form.

Based on a review of the available literature, best practice standards suggest up to ten days is sufficient
to assess student needs and develop a plan of action. Parents must be involved and may have to provide
food until the school can make appropriate accommodations. In the interim, it may also be possible to
use the Offer versus Serve Provision for school meals that allows students to decline certain menu items.
Many schools offer additional choices daily that would give students flexibility in selecting a meal.

References:

Child Find, Office of Special Education Programs, U.S. Department of Education
www.childfindidea.org
Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Office of Civil Rights Decisions, Seattle, Washington Public Schools (31 IDELR 193), Individuals with Disabilities
Education Law Report
http://web.diabetes.org/Advocacy/legalmaterials/LegalRights/LR‐Chap7.pdf
Offer versus Serve, Food and Nutrition Service, U.S. Department of Agriculture
www.fns.usda.gov/tn/resources/offer_v_serve.html

Who may write a Medical Statement for a student with a disability?

For students with a disability, a licensed physician must complete and sign the Medical Statement for
Students with Special Nutritional Needs for School Meals. Under no circumstances should school staff
interpret, revise or change a diet order.

References:

Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf
Title 7 ‐ Agriculture, Code of Federal Regulations, PART 15b ‐ Nondiscrimination on the Basis of Handicap in
Programs or Activities Receiving Federal Financial Assistance
www.access.gpo.gov/nara/cfr/waisidx_05/7cfr15b_05.html
N.C. Medical Board
www.ncmedboard.org/license_and_renewals/licensure_overview/
Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc

How much time does the LEA have to provide the student with the modified diet or texture change after the Medical Statement form has been submitted to the appropriate school staff?

The LEA has a reasonable amount of time (approximately 10 days determined by the Office of Civil Rights) to procure and provide the training necessary to appropriately fulfill the student's needs base on the Medical Statement Form.  

Until then the school staff is asked to colaborate with the aprents in order to determine how the student's dietary needs can be met.  In the mean time the school is not to alter the student's food.  The parents will be responsible for providing any foods within the modified diet.  

May a school nurse write a Medical Statement if there is a need for a food consistency modification
for a student with a disability?

No. All Medical Statements requiring dietary accommodations for students with disabilities must be
signed by a licensed physician.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf

What should the Child Nutrition administrator do when it appears that the Medical Statement may
not be completed by a licensed physician?

Contact the parent or guardian to discuss the Medical Statement. Clarify with the parent/guardian that
each special dietary request must be supported by a completed Medical Statement for Students with
Special Nutritional Needs for School Meals. For students with a disability, the Medical Statement must
be signed by a licensed physician. For students without a disability, the Medical Statement must be
signed by the licensed physician or a recognized medical authority, which includes a physician assistant
or nurse practitioner.

Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf
Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
How does one know if a physician is really licensed?

Contact the Medical Licensing Board for North Carolina if there is a question about the physician’s
practice.

References:

N.C. Medical Board
wwwapps.ncmedboard.org/Clients/NCBOM/Public/LicenseeInformationSearch.aspx

If diet order instructions are written on a prescription pad (and signed), do we still need the signed
Medical Statement?

Based on federal mandate from the United States Department of Agriculture (USDA), the N.C.
Department of Public Instruction requires a signed statement when making dietary accommodations for
students that includes the child's disability or medical condition, an explanation of why the disability or
medical condition restricts the child's diet, the major life activity affected, and the food or foods to be
omitted from the child's diet and the food or choice of foods that must be substituted. The Medical
Statement for Students with Special Nutritional Needs for School Meals is designed to collect all
information required by USDA when accommodating students with special dietary needs. This
information will be used by numerous people involved in the care of the student; therefore, the Medical
Statement must be completed to ensure all of the student’s nutritional needs are understood and can
be met by school staff. For students with a disability, the Medical Statement must be signed by a
licensed physician. For students without a disability, the Medical Statement must be signed by the licensed physician or a recognized medical authority, which includes a physician assistant or nurse
practitioner.

References:

Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf
Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc

The Medical Statement only specifies the medical disability and not the required food substitutions.
What should the Child Nutrition administrator do?

An appropriate school official (such as the Child Nutrition administrator or school nurse) must ask the
parent/guardian to obtain more written information from the licensed physician concerning the
substitutions or modifications the student requires. If difficulties arise in obtaining the needed
information, the parent/guardian should be advised of the problem and asked to work with the school
to obtain a completed Medical Statement for Students with Special Nutritional Needs for School Meals.
It is important that the family understand that the school is unable to provide food substitutions or
modifications without a completed and signed Medical Statement.
In some cases, it may be appropriate and helpful for the physician to provide a written referral to a
registered dietitian or other qualified professional for instructions regarding dietary substitutions or
modifications. For further guidance or referral to a registered dietitian, Child Nutrition administrators
may contact their State Agency.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf

Is a Medical Statement required for a student having an allergy and a learning disability or can the 504
Accommodation Plan/IEP suffice?

If dietary modifications are required, a completed and signed Medical Statement must be secured. For a
student with a disability, the Medical Statement must be signed by a licensed physician. For students
without a disability, the Medical Statement must be signed by the licensed physician or a recognized
medical authority, which includes a physician assistant or nurse practitioner. Based on federal mandate
from the United States Department of Agriculture (USDA), the N.C. Department of Public Instruction
requires a signed statement when making dietary accommodations for students that includes the child's
disability or medical condition, an explanation of why the disability or medical condition restricts the
child's diet, the major life activity affected, and the food or foods to be omitted from the child's diet and
the food or choice of foods that must be substituted.

The Medical Statement for Students with Special Nutritional Needs for School Meals has been formatted
to include all information required by USDA when accommodating students with special dietary needs. It
also includes information needed by the Individualized Education Plan Program (IEP) Team or 504
Accommodation Plan Committee and other professionals involved in developing plans to adequately
serve the needs of the student. When a student’s 504 Accommodation Plan or Individualized Education
Program (IEP) is being developed, the respective team must include the Child Nutrition administrator in
making decisions regarding accommodation of special dietary needs through the Child Nutrition
program.

Food anaphylaxis (life‐threatening allergy) is considered a disability. If the student’s allergy does not
result in anaphylaxis, it is still recommended to gather as much information as possible to best assist the
student; the Medical Statement can assist in obtaining complete details regarding the student’s allergy
and any requested dietary accommodations. The Local Education Agency (LEA), Child Nutrition program
may make food substitutions, at their discretion, for individual students who do not have a disability, but
who are medically certified as having a special medical or dietary need. Such determinations are made
by the LEA on a case‐by‐case basis. This provision covers those students who have food intolerances or
allergies but do not have life‐threatening reactions (anaphylactic reactions) when exposed to the food(s)
to which they have problems.

Under no circumstances should school staff interpret, revise or change a diet order.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf

Who may write a Medical Statement for students without a disability?

For students without a disability, the Medical Statement for Students with Special Nutritional Needs for
School Meals may be completed and signed by a licensed physician or a recognized medical authority,
which includes a physician assistant or nurse practitioner.

The Local Education Agency (LEA), Child Nutrition program may make food substitutions, at their
discretion, for individual students who do not have a disability, but who are medically certified as having
a special medical or dietary need. Such determinations are made by the LEA on a case‐by‐case basis. This
provision covers those students who have food intolerances or allergies but do not have life‐threatening
reactions (anaphylactic reactions) when exposed to the food(s) to which they have problems.

Under no circumstances should school staff interpret, revise or change a diet order.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf

What professionals are considered recognized medical authorities?

For students with a disability, a licensed physician must complete and sign the Medical Statement for
Students with Special Nutritional Needs for School Meals.
For students without a disability but with medically certified special dietary needs, the Medical
Statement for Students with Special Nutritional Needs for School Meals must be completed and signed
by a licensed physician or a recognized medical authority, which includes a physician assistant or nurse
practitioner.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf

How can I locate a pediatric registered dietitian (RD) or licensed dietitian/nutritionist (LDN) in North
Carolina who may serve as a resource for providing special nutrition services to students?

Local health departments, Federally Qualified Health Centers, hospitals, medical centers or school‐based
or school‐linked health centers that have registered dietitians on staff may be able to provide assistance
in understanding diet orders, developing and modifying meal plans and menus, acquiring special food
and beverage item purchases, and other aspects of feeding students with special needs.

References:

Directory of North Carolina Public Health Nutritionists, Nutrition Services Branch, N.C. Division of Public Health
www.nutritionnc.com/wic/wicLAR.htm
Find a Registered Dietitian, American Dietetic Association
www.eatright.org

Can a parent withdraw a Medical Statement (e.g., the parent does not agree with physician orders
written for texture modification or tube feeding)?

No, a parent or guardian cannot withdraw or modify a written Medical Statement. School staff must
adhere to the Medical Statement. Under no circumstances should school staff interpret, revise or
change a diet order.
If the parent/guardian does not agree with the Medical Statement for Students with Special Nutritional
Needs for School Meals, they may request a new evaluation from a licensed physician who then may
revise the Medical Statement. The school may be responsible for providing the medical evaluation.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc

If the school uses a health form must the Medical Statement be completed?

If dietary modifications are required, a completed and signed Medical Statement must be secured. For a
student with a disability, the Medical Statement must be signed by a licensed physician. For a student
without a disability, the Medical Statement must be signed by a licensed physician or recognized medical
authority, which includes a physician assistant or nurse practitioner. The Medical Statement for Students
with Special Nutritional Needs for School Meals has been formatted to include all information required
by the United States Department of Agriculture (USDA) when accommodating students with special
dietary needs. It also includes information needed by the district or school team and other professionals
involved in developing plans to adequately serve the needs of the student.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf

How often should Medical Statements be updated?

The United States Department of Agriculture (USDA) requires that the Medical Statement for Students
with Special Nutritional Needs for School Meals reflect the current dietary needs of the students. Some
Local Education Agencies (LEAs) may require that this information is updated annually. At a minimum,
the Medical Statement must be updated when the needs or condition of the student changes. If Medical
Statements are not renewed annually, LEAs should review the document regularly making sure it reflects
the current dietary needs of the student.

References:

Medical Statement for Students with Special Nutritional Needs for School Meals, Child Nutrition Services, N.C.
Department of Public Instruction
http://dpi.state.nc.us/docs/childnutrition/publications/special‐diet/medical‐statement.doc
Accommodating Children with Special Dietary Needs in School Nutrition Programs: Guidance for School Food
Service Staff. Alexandria, Va: U.S. Department of Agriculture, Food Nutrition Service; 2001.
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf

If parents provide food must the Medical Statement form be completed?

If the Local Education Agency (LEA), Child Nutrition program is not providing food or beverage for the
student, the Child Nutrition administrator will not need a completed Medical Statement for Students
with Special Nutritional Needs for School Meals.