Fillable Dietary Documentation Form - dietary accommodation request

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Dietary Documentation Form - dietary accommodation request

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The Dietary Documentation Form - dietary accommodation request form is 3 pages long and contains:

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File type: PDF

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DisabilitySupportServices
LARAMIECOUNTYCOMMUNITYCOLLEGE
1400EastCollegeDrive
Cheyenne,Wyoming82007
(307)778‐4385,Fax(307)778‐1262
Dietary Accommodation Request
(Student Request)
Name:
Student ID Number:
Phone Number:
Address:
What is your food allergy or medical diagnosis?
What is the impact or limitations associated with this allergy or medical condition?
What accommodations are you requesting related to your food allergy or medical condition?
Does this medical condition also impact you in the classroom? If so, please explain.
I understand that my request for dietary accommodations or modifications is not complete until medical
professional has also provided verification of my specific medical condition.
I agree that DSS office may collaborate with LCCC Dining Services and share my name, contact
information and relevant dietary information in order to determine appropriate dietary modifications.
Signature: Date:
DisabilitySupportServices
LARAMIECOUNTYCOMMUNITYCOLLEGE
1400EastCollegeDrive
Cheyenne,Wyoming82007
(307)778‐4385,Fax(307)778‐1262
Dietary Accommodation Request
(Student Request)
Students Name: Date of Birth:
The student listed above is requesting accommodations or modifications related to their food
allergy or other medical condition with regard to special dietary restrictions. In order to consider
this request for a reasonable accommodation related to their disability, Laramie County
Community College requires verification of the student’s medical condition from a health care
provider familiar with the student’s current condition and functional limitations.
What is the student’s food allergy or medical diagnosis?
What is the impact or limitations associated with this condition?
Are there specific dietary restrictions or precautions that should be considered?
What is the expected duration, stability or progression of the student’s condition (is this
temporary or permanent)?
Does this condition also impact the student in the classroom? If so, please explain.
Is there additional information we should be aware of in order to properly accommodate the
student related to their condition?
Certifying Professional:
Printed name:
Signature:
License number:
Address:
Telephone:
The requested documentation will be maintained by the DSS office per FERPA guidelines, and
will only be utilized to determine the student's request for meal modifications.
Please send the completed form, or responses addressed on your office letterhead to:
LaramieCountyCommunityCollege
DisabilityServicesforStudents
1400ECollegeDr
CheyenneWY82007
Tel:(307)778‐1359
Fax:(307778‐1262
TTY:(307)778‐1266
dss@lccc.wy.edu
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Dietary Documentation Form - dietary accommodation request

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Completed 15 February 2020

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