Special Diet Statement Form for Child Nutrition Programs
The Special Diet Statement form is used by institutions that sponsor federally funded Child Nutrition Programs to accommodate participants with dietary disabilities. This form must be filled out by a licensed medical professional. It requires detailed information about the participant's dietary needs and the necessary substitutions.
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How do I fill this out?
To fill out the Special Diet Statement form, you need to provide detailed participant information and specific dietary accommodations. This form must be completed by a licensed medical professional. Follow the instructions carefully to ensure accuracy.
How to fill out the Special Diet Statement Form for Child Nutrition Programs?
1
Provide participant's full name and contact information.
2
List the foods to be avoided and explain the effects on the participant.
3
List the foods to be substituted and provide texture modification details.
4
Include tube and oral feeding instructions if applicable.
5
Have a licensed medical professional sign and date the form.
Who needs the Special Diet Statement Form for Child Nutrition Programs?
1
Parents or guardians of children with dietary disabilities need this form to ensure their child's nutritional needs are met at school.
2
Licensed medical professionals use this form to document necessary dietary accommodations for their patients.
3
School nutrition staff require this form to prepare and serve the appropriate meals for participating students with dietary restrictions.
4
Childcare providers use this form to accommodate infants and toddlers with special dietary needs during meal and snack times.
5
Adult day care centers need this form to cater to participants with dietary restrictions due to disabilities.
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1
Upload the Special Diet Statement form to PrintFriendly.
2
Use the PDF editor to enter participant and dietary information.
3
Add any necessary dietary modifications and instructions.
4
Have a licensed medical professional review and sign the form.
5
Save and download the completed form for submission.
What are the instructions for submitting this form?
Submit the completed Special Diet Statement form to the appropriate institution or program director. Possible methods of submission include: Mailing to: U.S. Department of Agriculture, Office of the Assistant Secretary of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410. Faxing to: (202) 690-7442. Emailing to: program.intake@usda.gov. Always ensure you follow specific submission guidelines provided by the institution or program.
What are the important dates for this form in 2024 and 2025?
Ensure timely submission of the Special Diet Statement form for the academic years 2024 and 2025 as required by your institution or program guidelines.
What is the purpose of this form?
The purpose of the Special Diet Statement form is to provide a standardized method for documenting and communicating dietary accommodations for participants with disabilities in federally funded Child Nutrition Programs. This form ensures that institutions and organizations can meet the specific dietary needs of participants safely and consistently. By completing this form, parents, guardians, and medical professionals can work together to support the health and well-being of children and adults with dietary restrictions. The form also helps institutions comply with federal guidelines and regulations concerning dietary accommodations. It outlines the necessary information required for making meal and snack modifications, including the types of foods to be avoided, the effects of exposure, and the appropriate substitutions. Additionally, it includes sections for texture modifications, tube and oral feeding instructions, and other dietary modifications. Completing the Special Diet Statement form accurately and thoroughly is essential for ensuring that participants receive the necessary dietary support while attending schools, childcare centers, or adult day care facilities. This collaborative approach fosters an inclusive environment where all participants have equal access to nutritious meals tailored to their specific needs.
Tell me about this form and its components and fields line-by-line.
- 1. Participant Information: Includes the participant's full name, date of birth, and contact information.
- 2. Parent/Guardian Information: Includes the name, home phone number, and work phone number of the parent or guardian.
- 3. Dietary Accommodation: Details the foods to be avoided, effects of exposure, and foods to be substituted.
- 4. Texture Modification: Specifies texture modifications needed, such as pureed, ground, or bite-sized pieces.
- 5. Tube Feeding: Provides instructions for administering formula and oral feeding specifics.
- 6. Required Signature: Includes the signature, credentials, and contact information of the licensed medical professional.
- 7. Voluntary Authorization: Allows the parent/guardian to authorize the exchange of protected health information for special diet purposes.
- 8. Non-Discrimination Statement: Outlines federal civil rights regulations and non-discrimination policies for USDA programs.
What happens if I fail to submit this form?
Failure to submit the Special Diet Statement form may result in the participant not receiving necessary dietary accommodations.
- Unmet Dietary Needs: Participants may not receive meals and snacks tailored to their dietary restrictions.
- Non-Compliance: Institutions may not comply with federal guidelines, leading to potential repercussions.
- Health Risks: Participants may face health risks due to exposure to foods they need to avoid.
How do I know when to use this form?
- 1. School Meal Programs: For students needing special diets in school nutrition programs.
- 2. Childcare Centers: For children in childcare centers requiring dietary modifications.
- 3. Adult Day Care: For adults in day care programs with dietary restrictions.
- 4. Summer Food Programs: For participants in summer meal programs requiring dietary accommodations.
- 5. Early Learning Centers: For infants and toddlers in early learning centers with specific dietary needs.
Frequently Asked Questions
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How do I share the completed Special Diet Statement form?
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Do I need a licensed medical professional to fill out the form?
Yes, the form must be completed by a licensed physician, physician assistant, or nurse practitioner.
What information is required in the form?
You need to provide participant details, foods to avoid, substitutions, and medical professional's signature.
Can I save the edited form on PrintFriendly?
Yes, after editing, you can save and download the updated form for your records.
Is there a deadline for submitting the Special Diet Statement form?
Forms should be submitted as required by the institution or program guidelines.
Can I request lactose-free milk without a physician's signature?
Yes, parents or guardians can request lactose-free milk with a written request meeting meal pattern requirements.
What if a participant's needs change after submitting the form?
Updates to the form are required if the participant's dietary needs change.
Where can I find additional instructions for filling out the form?
Refer to the detailed instructions provided within the Special Diet Statement form or the institution's guidelines.
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