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N.C. Department of Public Instruction | School Nutrition Services Revised 6/2017
Guidance for Completing the Medical Statement for Students
with Unique Mealtime Needs for School Meals
PART A - PARENT/GUARDIAN
The Medical Statement for Students with Unique Mealtime Needs for School Meals helps schools provide meal modifications for students who require
them. Schools cannot change food textures, make food substitutions, or alter a student’s diet at school without proper documentation from the
healthcare providers. Completion of all items will allow your child’s school to create a plan with you for providing safe, appropriate meals and snacks
to your child while at school.
Your participation in this process is very important. The sooner you provide this signed and completed form to your child’s school, the sooner the
School Nutrition Program and their staff can prepare the food your child needs. Your signature is required for your school to take action on the
Medical Statement.
Follow these steps to get started:
1) Complete all sections of PART A of the Medical Statement.
2) Take the Medical Statement to your child’s pediatrician or family doctor/nurse practitioner/physician’s assistant and have him/her complete
PART B.
3) RETURN THE FULLY COMPLETED MEDICAL STATEMENT WITH SIGNATURES FROM BOTH PARENT/GUARDIAN AND MEDICAL AUTHORITY, TO YOUR
CHILD’S TEACHER, PRINCIPAL, NURSE, SPECIAL EDUCATION CASE MANAGER, OR SECTION 504 CASE MANAGER, SCHOOL NUTRITION
ADMINISTRATOR, OR THE SCHOOL STAFF PERSON WHO GAVE YOU THE BLANK FORM.
4) Ask the school when a team, including you, the school system’s School Nutrition Administrator and others, will meet to consider the information
provided on the form. You may also invite people from the community who are knowledgeable about your child’s feeding and nutrition issues to
the meeting. These would be people who could help school staff design a school mealtime plan for your child, like your child’s pediatrician,
nurse, speech-language pathologist, occupational therapist, registered dietitian or personal care aide.
PART B – RECOGNIZED MEDICAL AUTHORITIES (Licensed physician, physician assistant, and nurse practitioner)
A Recognized Medical Authority’s signature is required for students with a disability. Schools cannot change food textures, make food substitutions, or
alter a student’s diet at school without proper documentation from the healthcare providers. Meal modifications are implemented based on medical
assessment and treatment planning and must be ordered by a recognized medical authority.
Please consider the following as you complete PART B of the Medical Statement:
1) Complete all sections of PART B. Completion of all items will streamline efficient care of the student at school.
2) Be as specific as possible about the nature of the student’s physical or mental impairment, its impact on the student’s diet and major life activities
that are affected. In the case of food allergy, please indicate if the student’s condition is a food intolerance, an allergy that would affect performance
and participation at school (e.g., severe rash, swelling, and discomfort), or a life-threatening allergy (e.g., anaphylactic shock).
3) If your assessment of the child does not yield sufficient data to make a determination about food substitutions, consistency modifications, or other
dietary restrictions, please refer the child/family to the appropriate health care professional for completion of the assessment. Schools do not
routinely have instrumentation and/or staff trained for a comprehensive nutrition and feeding assessment and must partner with community
providers to meet a student’s unique feeding and nutrition needs.
4) Attach any previous and/or existing feeding/nutrition evaluations, care plans, or other pertinent documentation housed in the student’s medical
records to the Medical Statement for parent/guardian delivery to the school.
5) Consider being available to consult with the student’s mealtime planning team as it implements the feeding/nutrition care plan.
PART C – SCHOOL NUTRITION ADMINISTRATOR and IEP/504 REPRESENTATIVE
Please consider the following as you complete PART C of the Medical Statement:
Signature of the School Nutrition Administrator and 504 Coordinator or IEP Case Manager/EC Program representative indicates the medical statement
has been received, reviewed, and a plan to address the student’s unique mealtime needs is being developed/implemented.
USDA Nondiscrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and
employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,
disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language,
etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact
USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information
requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
N.C. Department of Public Instruction | School Nutrition Services Revised 6/2017
Medical Statement for Students with Unique Mealtime Needs for School Meals 2
Medical Statement for Students with Unique Mealtime Needs for School Meals
When completed fully, this form gives schools the information required by the U.S. Department of Agriculture (USDA), U.S. Office for Civil Rights (OCR), and U.S.
Office of Special Education and Rehabilitative Services (OSERS) for meal modifications at school. See “Guidance for Completing Medical Statement for Students
with Unique Mealtime Needs for School Meals” (previous page) for help in completing this form.
PART A (To be completed by PARENT/GUARDIAN)
STUDENT INFORMATION
Last Name:
First Name:
Date of Birth
School:
Grade
Student ID#
SELECT the school-
provided meals and/or
snacks in which this
student will participate:
School Breakfast Program National School Lunch Program Afterschool Snack Program
Afterschool Supper Program Fresh Fruit & Vegetable Program
PARENT/GUARDIAN
CONTACT INFORMATION
Printed Name of PARENT/GUARDIAN:
Mailing Address:
City:
State:
Zip Code:
Work Phone:
Home Phone:
Mobile Phone:
Email:
Please describe the
concerns you have about
your student’s nutritional
needs at school:
Please describe the
concerns you have about
your student’s ability to
safely participate in
mealtime at school?
Does the student already have an Individualized Education Program (IEP)?
YES NO
NOTE: Unique mealtime needs for students without an
IEP, 504 or disability, but with general health concerns,
are addressed within the meal pattern at the discretion
of the School Nutrition Administrator and policies of the
school district.
Does the student already have a 504 Plan?
YES NO
PARENT/GUARDIAN
Consent
I agree to allow my child's health care provider and school personnel to communicate as needed regarding the
information on this form.
Parent/Guardian Signature Date
Please return this fully completed Medical Statement with signatures from both parent/guardian and medical authority, to your
child’s teacher, principal, nurse, Special Education case manager, or Section 504 case manager, School Nutrition Administrator, or
the school staff person who gave you the blank form.
N.C. Department of Public Instruction | School Nutrition Services Revised 6/2017
Medical Statement for Students with Unique Mealtime Needs for School Meals 3
STUDENT NAME:
STUDENT ID#:
PART B (To be completed by a RECOGNIZED MEDICAL AUTHORITY, i.e., Licensed physicians, physician assistants, and nurse practitioners)
Describe the student’s physical or mental impairment:
Explain how the impairment restricts the student’s diet:
Major life activities
affected:
Select all that apply.
Walking Seeing Hearing Speaking Performing manual tasks
Learning Breathing Self-Care Eating/Digestion
Other (please specify):
Is this a Food Allergy? YES NO
Is this a Food Intolerance? YES NO
If student has life threatening allergies* check appropriate box(es):
*Students with life threatening food allergies must have an emergency action plan in place at school.
Ingestion Contact Inhalation
Specify any dietary restrictions or special diet instructions for accommodating this student in school meals:
For any special
diet, list specific
foods to be
omitted and the
recommended
substitutions.
(You may attach a
separate care plan)
Foods to be Omitted
Recommended
Substitutions
Foods to be Omitted
Recommended
Substitutions
Designate safest consistency requirement for FOOD:
Designate safest consistency requirement for LIQUIDS:
Pureed Mechanical Soft
Ground Chopped
Other (please specify):
Clear Liquid Nectar-thick
Full Liquid Honey-thick
Pudding-thick
Other (please specify):
Other comments about the child’s eating or feeding patterns, including tube feeding if applicable:
*NOTE* If your assessment of the child does
not yield sufficient data to fully complete the
above sections applicable to the student’s
mealtime needs, please refer the child/family
to the appropriate health care professional
for completion of the assessment.
Signature of Recognized Medical Authority*
Printed Name
Phone Number
( )
Date
* A recognized medical authority in N.C. includes licensed physicians, physician assistants and nurse practitioners.
PART C (To be completed by SCHOOL DISTRICT ADMINISTRATORS)
NOTES: (School Nutrition or other School Program staff)
School Nutrition Administrator’s Signature: Date:
IEP/504 Coordinator Signature: Date:
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Completed 10 January 2021

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