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Meal Modification Form
Meal Modification Form
Mae Joslin
Friday, April 05, 2019

If your student is allergic to any type of food and needs a modification for school breakfast or lunches, please fill out the Meal Modification form. The form is located in each school's office and needs to be updated each school year. Please feel free to contact Nurse Amy if you have any questions at mosiera@rv337.org

Medical Statement to Request School Meal Modification

Important! Select the applicable meal modification category from the three listed below. Then carefully read and follow the
procedures for that category. The school will return incomplete Medical Statements to the parent/guardian. If you have questions about this form, the school contact named in Part A below will assist you.

1. Modification due to a disability:
-A school is required to make meal modifications prescribed by a medical authority to accommodate a student’s
disability. See the definition of disability on the back of this form.
-Part B of this form must be completed by a “medical authority” that is authorized by Kansas state law to write medical
prescriptions: licensed physician (MD or DO) OR a physician’s assistant (PA) or an advanced registered nurse
practitioner (ARNP) authorized by their responsible licensed physician.
-Parts A and C of this form must also be completed before the school can make meal modifications.
-The meal modifications will continue until the medical authority requests that the modifications be changed or stopped
on Form 19-C, which is available from the school.
-It is strongly recommended that the medical authority annually update the prescribed diet order.


2. Modification due to a food allergy/intolerance, or other medical condition that does not rise to the level of a
disability:
-A school has the option to make meal modifications prescribed by a medical authority due to a food allergy/intolerance
or other medical condition that does not rise to the level of a disability.
-Part B of this form must be completed by a “medical authority” that is authorized by Kansas state law to write medical
prescriptions: licensed physician (MD or DO) OR a physician’s assistant (PA) or an advanced registered nurse
practitioner (ARNP) authorized by their responsible licensed physician.
-Parts A and C of this form must also be completed before the school can make meal modifications.
-If a school chooses to make the meal modifications, they will continue until a medical authority requests that the
modifications be changed or stopped on Form 19-C, which is available from the school.
-It is strongly recommended that a medical authority annually update the prescribed diet order.


3. Substitution for fluid cow’s milk due to lactose intolerance, allergy, vegan diet, religious, ethical or cultural reasons:
-A school has the option to make a substitution for fluid cow’s milk that is requested by a parent/guardian, but that is not
prescribed by a medical authority.
-Parts A and D of this form must be completed before the school can make a substitution for fluid cow’s milk.
-If a school chooses to provide such a substitution, they will continue until a parent/guardian requests that the
substitution be changed or stopped on Form 19-C, which is available from the school.
Part A. Student, Parent/Guardian & School Contact Information – To be completed by a parent/guardian or school contact person
Student’s Name: Date of Birth: School:
Parent/Guardian’s Name: Parent/Guardian’s Phone:
School Contact’s Name: School Contact’s Phone:
Part B. Prescribed Diet Order – This part must be completed by a medical authority as specified above.


1. Check ONE:
Disability OR Food allergy/intolerance or other medical condition that does not rise to the level of a disability
2. Specify the disability, food allergy/intolerance or medical condition related to the prescribed diet order.

3. If the student has a disability, what major life activity is affected? Example: Allergy to peanuts affects ability to breathe.

4. Type of Special Diet:
Check if not applicable OR specify the type of special diet (e.g. low sodium, gluten-free, diabetic, etc.).

09/2016 Child Nutrition & Wellness, Kansas State Department of Education Form 19-B
5. Modified Texture: Not Applicable Chopped Ground Pureed
6. Modified Thickness of Liquids: Not Applicable Nectar Honey Spoon or
Pudding Thick

7. Special Feeding Equipment:
Check if not applicable OR list special feeding equipment (e.g. large handled spoon, sippy cup, etc.).


8. Foods to be Omitted and Substituted:
Check if not applicable OR list specific foods to be omitted and substituted. If more space is needed, sign and attach additional
sheet of paper.
IMPORTANT: For a student who does not have a recognized disability, the only fluid cow’s milk substitutions allowed by USDA are:
(1) lactose-free fluid cow’s milk or (2) a non-dairy beverage with a nutrient profile equivalent to fluid cow’s milk as specified in federal
regulations. Currently the only beverages meeting these specifications are certain brands of soymilk.
Omit Foods Listed Below: Substitute Foods Listed Below:

9. Medical Authority’s Information
Signature: 

Title:

Printed Name:

Phone: 

Date:


Part C. Parent/Guardian Permission – To be completed by a parent/guardian
I give permission for school personnel responsible for implementing my child’s prescribed diet order to discuss my child’s special dietary accommodations with any appropriate school staff and to follow the prescribed diet order for my child’s school meals. I also give permission for my child’s medical authority to further clarify the prescribed diet order on this form if requested to do so by school personnel.


Parent/Guardian’s Signature:  

Date:


Part D. Request Substitution for Fluid Cow’s Milk due to Lactose Intolerance, Allergy, Vegan Diet, Religious, Cultural or
Ethical Reasons – To be completed by a parent/guardian
Instead of fluid cow’s milk, please provide the student named in Part A. of this form with the following substitute (Check ONE):
Lactose-free cow’s milk Non-dairy beverage with a nutrient profile equivalent to fluid cow’s milk per federal regulations
Parent/Guardian’s Signature: Date:
Definition of Disability:
Under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA), a “person with a disability” means
“any person who has a physical or mental impairment which substantially limits one or more major life activity, has a record of such
impairment, or is regarded as having such an impairment.”
Major life activities covered by this definition include caring for one’s self, eating, performing manual tasks, walking, seeing, hearing,
speaking, breathing, learning, working and major bodily functions. The term “physical or mental impairment” includes, but is not limited
to, such diseases, conditions, and functions as:

-Orthopedic, visual, speech and hearing impairments

-Cardiovascular, circulatory and heart
-Cerebral Palsy, Epilepsy, Muscular Dystrophy and Multiple Sclerosis

-Metabolic and endocrine

-Digestive, bowel and bladder 

-Food anaphylaxis (severe food allergy)

-Neurological and brain 

-Intellectual disability
-Respiratory 

-Emotional illness
- Cancer 

-Drug addiction and alcoholism
Individuals who take mitigating measures to improve or control any of the conditions recognized as a disability are still considered to have a disability and require an accommodation.