Request Special Meals - Los Angeles Unified School District

INTEROFFICE CORRESPONDENCE Los Angeles Unified School District TO:

Food Services Manager (FSM)

FROM:

Food Services Division

DATE: April 28, 2014

SUBJECT: Procedure for Requesting Special Meals-REVISED 1. Provide Medical Statement to Request Special Meals (2014-2015) form and instructions to the parent/guardian requesting a special diet for his/her child. 2. Review the form with the parent/guardian to see if she/he has any questions. 3. When you receive the form back: a. Make sure all fields in “Section A (Parent/Guardian) & Section C (Medical Authority)” are filled out. b. Complete all fields in “Section B (LAUSD FSM)” 4. Keep the original copy of the completed form for your records and email a SCANNED Copy to your regional (ESC=Educational Service Center) Nutrition Specialist: [email protected] [email protected] [email protected] [email protected]

ESC/SISIC North ESC/SISIC East ESC/SISIC South ESC/SISIC West

FSM’s: Please know your ESC and fill in #11 on the Medical Statement. 5. Once the request is reviewed and the process is completed by the Nutrition Specialist, the FSM will be informed by email with an approved diet or why a particular special meal request is denied. 6. The FSM must provide a copy of the special diet information to the parent/guardian and school nurse. 7. The FSM is responsible for ordering and providing all special meals including NNC (Newman Nutrition Center) meals. 8. If the student does not follow the specially prepared diet for a 2 week period, the FSM must contact the Nutrition Specialist and the special meals/special diet will be cancelled. 9. Omission of any information on the form will cause it to be returned for completion, and/or delay the entire process. 10. If more than one special diet request is submitted for a student during the same school year, the diet will be based ONLY on the information provided in the most recent Medical Statement. Prior Special Diet Requests and Medical Statements will become invalid. 11. Special diet requests for the 2014-2015 school year will be accepted starting May 1, 2014. Diets written for the 2013-2014 will not “carry over” or “continue on” for the 2014-2015 school year. A new special diet request is needed.

MEDICAL STATEMENT TO REQUEST SPECIAL MEALS (2014-2015)

4/28/2014

A. Parent/Guardian: Complete the following (1- 8) 1. Student Last Name (Apellido)

2. Student First Name

3. Student ID #

(Nombre del estudiante)

(ID del estudiante)

4. Date of Birth

5. Check Meals Eaten at School

(Fecha de nacimiento)

(Marque las comidas que su niño/a come en la escuela)

Breakfast

Lunch

Snack

(Desayuno)

(Amuerzo) Supper (Cena)

6. Parent/GuardianSignature

7. Parent/Guardian Name

(Firma del Padres/Tutor)

(Bocadillo)

8. Parent/Guardian Phone #

(Escriba en letra de molde el nombre del padres)

(Numero(s) de teléfono del padres)

Home (Casa): ( Cell (Celular): (

) )

B. Food Services Manager (FSM): Complete the following (9-17) 9. School Name (Include EEC name, if applicable) 13. School Phone # ( ) 15. FSM Name

10. Loc. Code #

11. ESC/SISIC

12. Kitchen Type: Prep

14. School Fax # ( ) 16. FSM Email

NNC

17. Cafeteria Phone # ( )

C. Medical Authority: Complete the following (18-29) 18. CHECK ONE: Student has a disability or a medical condition and REQUIRES a special meal. (Refer to definitions in the instructions page.) Schools and agencies participating in federal nutrition programs must comply with requests for special meals. A licensed physician must sign this form. Student does not have a disability, but is requesting a special meal due to food intolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schools and agencies participating in federal nutrition programs are encouraged but not required to accommodate reasonable requests. A licensed physician, physician assistant, or nurse practitioner must sign this form. 19. DISABILITY OR MEDICAL CONDITION REQUIRING A SPECIAL MEAL: 20. IF STUDENT HAS A DISABILITY, PROVIDE A BRIEF DESCRIPTION OF THE STUDENT’S MAJOR LIFE ACTIVITY AFFECTED BY THE DISABILITY:

21. DIET PRESCRIPTION: (PLEASE DESCRIBE IN DETAIL TO ENSURE PROPER IMPLEMENTATION.)

22. INDICATE TEXTURE:

Regular

Chopped

Ground

Pureed

23. FOODS TO BE OMITTED AND SUBSTITUTIONS: (PLEASE LIST SPECIFIC FOODS TO BE OMITTED AND SUGGESTED SUBSTITUTIONS. YOU MAY ATTACH A SHEET WITH ADDITIONAL INFORMATION.) A. Foods To Be Omitted B. Suggested Substitutions

24. Medical Authority’s Name

25. Medical Authority’s Signature

27. Medical Authority’s Phone # ( )

28. Date

26. Medical License #

29. Name/Phone # of Registered Dietitian following student:

MEDICAL STATEMENT TO REQUEST SPECIAL MEALS (2014-2015) INSTRUCTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

4/28/2014

Parent/Guardian completes Section “A” and Medical Authority completes Section “C” of the form. Return the completed form to the Food Services Manager (FSM). Incomplete request forms will not be processed. All fields of the form must be filled in. FSM sends the completed form to regional Nutrition Specialist/Registered Dietitian (NS). The NS processes it and sends the special diet to the FSM. FSM keeps the special diet on file and gives a copy to the parent/guardian and school nurse. If the student does not follow the specially prepared diet for a 2-week period, the special meals/special diet will be cancelled. Any student requiring Special Meals must have a new form completed annually beginning in July. Completed Special Diet Request forms will not be carried over from year to year. Special meals are not provided to accommodate personal preferences or religious convictions. You may visit the LAUSD website at http://cafe-la.lausd.net and print the monthly menu, “Food Allergen and Ingredient List”, and “Nutrition Analysis and Carbohydrate Count”. Lactose Free milk is offered without documentation to students who are lactose intolerant to milk only. Soy milk is offered as a milk substitute, and will be provided to students who have a completed “Parental Request for a Fluid Milk Substitution for School-Age Children” form, or a “Medical Statement to Request Special Meals”. Both forms are available from the FSM, and on the LAUSD website.

DEFINITIONS: Special Dietary Needs of Students WITH Disabilities Nutrition Services Division is required to offer special meals for children whose disabilities restrict their diets as defined in USDA regulations 7 CFR Part 15b and when food allergies may result in severe, lifethreatening (anaphylactic reactions) and that need is supported by a statement signed by a licensed physician. Special Dietary Needs of Students WITHOUT Disabilities Nutrition Services Division may make food substitutions, at their discretion, for individual children who do not have a disability, but who are medically certified as having a special medical or dietary need. Such determinations are only made on a case-by-case basis. This provision covers those children who have food intolerances or allergies but do not have life-threatening (anaphylactic reactions) when exposed to the food(s) to which they have problems. “A Person with a Disability”* is defined as 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. “Physical or mental impairment”* means (a) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive, digestive, genito-urinary; hemic and lymphatic; skin; and endocrine; or (b) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. “Major life activities”* include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. “Has a record of such an impairment”* is defined as having a history of, or having been classified (or misclassified) as having a mental or physical impairment that substantially limits one or more major life activity. (*Citations from Section 504 of the Rehabilitation Act of 1973 and Americans with Disabilities Act of 1990)