English/Spanish Packet to Go Home With Student for:

BAKERSFIELD CITY SCHOOL DISTRICT

NUTRITION SERVICES DEPARTMENT

1300 BAKER ST. – EDUCATION CENTER

BAKERSFIELD, CA 93305

(661) 631-4733 Fax: (661) 322-8580

English/Spanish

Packet to Go Home With

Student for:

Medical Statement to Request Special

Meals and/or Accommodations

(Special Dietary Needs)

Revised 7/1/16

To:

The Parents of: ________________________

School: ______________________________

Date: ________________________ School Year: 2016-2017

From:

Brenda Robinson, Director – [email protected]

Nutrition Services Department

Debbie Wood, Coordinator – [email protected]

School Health and Neighborhood Support Programs

Subject: Medical Statement to Request Special Meals and/or Accommodations/Special Dietary needs for Students

Attached you will find an Attending Physician letter and a form that requires a Physician review and

signature. Before we can adequately accommodate your student’s special dietary needs,

you must have the attached form completed and signed by your child’s Physician. After your Physician has

completed and signed the Medical Statement forms it must be faxed or mailed to the Nutrition Services

Department at 1300 Baker Street Bakersfield, CA 93305, Fax Number: (661) 322-8580.

To be in compliance with state regulations, we must have the Medical Statement forms on file at the school

site and at the Nutrition Services Department. The Medical Statement is valid for one year from the date

signed and must be updated yearly. If this form is not updated yearly we will not be able to accommodate

your child’s special dietary needs.

Please respond to the box that is checked below:

□ We need an updated Medical Statement form signed by your child’s Physician.

□ We do not have a current Medical Statement on file for your child and have a pending note to

accommodate your child’s Special dietary needs.. We must have a current, signed Medical Statement

signed by a Physician as soon as possible to continue providing for your child’s special dietary needs.

□ I have already submitted a current, Physician signed Medical Statement to:

Name of Person:____________________________

Located at:________________________________

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: [email protected].

This institution is an equal opportunity provider.

BAKERSFIELD CITY SCHOOL DISTRICT

Nutrition Services Department 1300 Baker Street Bakersfield, CA 93305-4326

(661) 631-4733 Brenda Robinson

Director

EDUCATION CENTER, 1300 BAKER STREET

BAKERSFIELD, CALIFORNIA 93305-4326

(661) 631-4733

FAX: (661) 322-8580

Para:

Los padres de: __________________Escuela___________________ Fecha____________

De:

Brenda Robinson, directora – [email protected]

Departamento de Servicios de Nutrición

Debbie Wood, coordinadora –[email protected]

Departamento de Servicios de Salud

Fecha:

Año escolar 2016-2017

Asunto: Necesidades dietéticas especiales para el estudiante

Adjunto encontrará una carta de presentación y un formulario que requiere la revisión y firma de un médico. Antes

de que podamos ajustar adecuadamente las necesidades dietéticas especiales de su estudiante, por favor pida al

médico de su niño que llene y firme los formularios apropiados. Después de obtener la firma de su médico, puede

enviar los formularios por fax o por correo a la Oficina de Servicios de Nutrición al domicilio anotado arriba.

Para estar en cumplimiento con el reglamento del Estado, debemos tener estos formularios archivados en la escuela

y en la oficina central. Los formularios son válidos por un año a partir de la fecha en que fueron firmados y se

deben actualizar cada año. Si estos formularios no se actualizan cada año no podremos ajustar las necesidades de

dieta especial de su hijo.

Favor de responder al asunto marcado con a continuación:

Necesitamos un formulario actualizado por el doctor (Dr.) para su niño

No tenemos en nuestros archivos una nota del doctor para su niño y tenemos pendiente una nota para ajustar la

dieta especial de su niño. Necesitamos una nota del doctor lo más pronto posible para continuar proveyendo al niño

una dieta especial.

He devuelto la forma de doctor a: ________________________________

________________________________

De conformidad con la Ley Federal de Derechos Civiles y los reglamentos y políticas de derechos civiles del Departamento de Agricultura de los EE. UU. (USDA, por sus siglas en inglés), se prohíbe que el USDA, sus agencias, oficinas, empleados e instituciones que participan o administran programas del USDA discriminen sobre la base de raza, color, nacionalidad, sexo, discapacidad, edad, o en represalia o venganza por actividades previas de derechos civiles en algún programa o actividad realizados o financiados por el USDA.

Las personas con discapacidades que necesiten medios alternativos para la comunicación de la información del programa (por ejemplo, sistema Braille, letras grandes, cintas de audio, lenguaje de señas americano, etc.), deben ponerse en contacto con la agencia (estatal o local) en la que solicitaron los beneficios. Las personas sordas, con dificultades de audición o discapacidades del habla pueden comunicarse con el USDA por medio del Federal Relay Service [Servicio Federal de Retransmisión] al (800) 877-8339. Además, la información del programa se puede proporcionar en otros idiomas.

Para presentar una denuncia de discriminación, complete el Formulario de Denuncia de Discriminación del Programa del USDA, (AD-3027) que está disponible en línea en: http://www.ascr.usda.gov/complaint_filing_cust.html y en cualquier oficina del USDA, o bien escriba una carta dirigida al USDA e incluya en la carta toda la información solicitada en el formulario. Para solicitar una copia del formulario de denuncia, llame al (866) 632-9992. Haga llegar su formulario lleno o carta al USDA por:

(1) correo: 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; o

(3) correo electrónico: [email protected].

Esta institución es un proveedor que ofrece igualdad de oportunidades.

BAKERSFIELD CITY SCHOOL DISTRICT

Nutrition Services Department 1300 Baker Street Bakersfield, CA 93305-4326

(661) 631-4733 Brenda Robinson

Director

EDUCATION CENTER, 1300 BAKER STREET

BAKERSFIELD, CALIFORNIA 93305-4326

(661) 631-4733

FAX: (661) 322-8580

(Lugar donde se presentó la

(Persona la forma fue presentado a)

To:

Attending Physician

2016-2017 School Year

From:

Brenda Robinson, Director –

[email protected]

Nutrition Services Department

Debbie Wood, Coordinator –

[email protected]

School Health and Neighborhood Support Programs

Subject:

Medical Statement to Request Special Meals and/or Accommodations

Special Dietary Needs for Student

Attached you will find a Medical Statement form pertaining to special dietary needs. In order

to comply with USDA government regulations in accommodating a student’s needs, we must

have legal documentation identifying those needs from an attending medical authority on file

in our Nutrition Services Department. A medical authority must indicate by checking the

appropriate box if the child has a disability or medical condition.

** If the allergy is peanuts/nut products, indicate if the child is affected by

ingestion, inhalation, skin absorption or any combination.

Please complete the form and fax a copy to:

BAKERSFIELD CITY SCHOOL DISTRICT

Nutrition Services Department

(661) 322-8580

Or mail a copy to:

BAKERSFIELD CITY SCHOOL DISTRICT

Nutrition Services Department

1300 Baker Street

Bakersfield, CA 93305

Please note: the Medical Statement does not become an official document until signed by the

correct, appropriate, medical party: a licensed Physician, Physician’s Assistant, or Nurse

Practitioner only. A RN (Registered Nurse) cannot sign this form as the recognized medical

authority. Forms are valid for one year from the date signed and must be updated yearly. If

this form is not updated yearly we will not be able to accommodate the child’s special

dietary needs.

Thank you for your assistance in this matter.

BAKERSFIELD CITY SCHOOL DISTRICT

Nutrition Services Dept. 1300 Baker Street Bakersfield, CA 93305-4326

(661) 631-4733 Brenda Robinson

Director

EDUCATION CENTER, 1300 BAKER STREET

BAKERSFIELD, CALIFORNIA 93305-4326

(661) 631-4733

FAX: (661) 322-8580

MEDICAL STATEMENT TO REQUEST

SPECIAL MEALS AND/OR ACCOMMODATIONS (REVISED 7/1/16)

1.

/

2.

3.

4.

5.

6.

/

7.

8.

:

Participant has a disability or a medical condition and requires a special meal or accommodation. (Refer to definitions on reverse side

of this form.) Schools and agencies participating in federal nutrition programs must comply with requests for special meals and any

adaptive equipment.

Participant does not have a disability, but is requesting a special meal or accommodation 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 to accommodate reasonable requests. A licensed physician, physician’s assistant, or nurse practitioner

must sign this form.

9.

:

10.

,

’

:

11.

/

: (

)

12.

:

Regular

Chopped

Ground

Pureed

13. 13.

: (

.

)

A

.

Foods To Be Omitted

.

Suggested Substitutions

14.

:

IHEREBYGIVECONSENTFORASCHOOLNURSEORDISTRICTADMINISTRATORTOCOMMUNICATEWITHMYCHILD’SCALIFORNIAPHYSICIANORCALIFORNIA LICENSEDCAREPROVIDER,AND

SCHOOLPERSONNELASNEEDEDWITHREGARDTOTHSREQUESTFORSPECIALDIET

.

15.

/

16. Signature of Preparer *

17. Printed Name

18.

19.

20.Signature of Medical Authority*

21.Printed Name

22.

23.

should be updated to reflect the current medical and/or nutritional needs of the participant.

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

MEDICAL STATEMENT TO REQUEST

SPECIAL MEALS AND/OR ACCOMMODATIONS

INSTRUCTIONS

1.

School/Agency: Print the name of the school or agency that is providing the form to the parent.

2.

Site: Print the name of the site where meals will be served (e.g., school site, child care center, community center,

etc.)

3.

Site Telephone Number: Print the telephone number of site where meal will be served. See #2.

4.

Name of Participant: Print the name of the child or adult participant to whom the information pertains.

5.

Age of Participant: Print the age of the participant. For infants, please use Date of Birth.

6.

Name of Parent or Guardian: Print the name of the person requesting the participant’s medical statement.

7.

Telephone Number: Print the telephone number of parent or guardian.

8.

Check One: Check ( ) a box to indicate whether participant has a disability or does not have a disability.

9.

Disability or Medical Condition Requiring a Special Meal or Accommodation: Describe the medical condition that

requires a special meal or accommodation (e.g., juvenile diabetes, allergy to peanuts, etc.)

10. If Participant has a Disability, Provide a Brief Description of Participant’s Major Life Activity Affected by the

Disability: Describe how physical or medical condition affects disability. For example: ”Allergy to peanuts causes a

life-threatening reaction.”

11. Diet Prescription and/or Accommodation: Describe a specific diet or accommodation that has been prescribed by

a physician, or describe diet modification requested for a non-disabling condition. For example: ”All foods must be

either in liquid or pureed form. Participant cannot consume any solid foods.”

12. Indicate Texture: Check ( ) a box to indicate the type of texture of food that is required. If the participant does not

need any modification, check “Regular”.

13.

A

.

Foods to Be Omitted: List specific foods that must be omitted. For example, the “exclude fluid milk.”

B

. Suggested Substitutions: List specific foods to include in the diet. For example, “calcium fortified juice.”

14. Adaptive Equipment: Describe specific equipment required to assist the participant with dining. (Examples may

include a sippy cup, a large handled spoon, wheel-chair accessible furniture, etc.)

15

Signature of Preparer: Signature of person completing form.

16. Printed Name: Print name of person completing form.

17. Telephone Number: Telephone number of person completing form.

18. Date: Date preparer signed form.

19. Signature of Medical Authority: Signature of medical authority requesting the special meal or accommodation.

20. Printed Name: Print name of medical authority.

21. Telephone Number: Telephone number of medical authority.

22. Date: Date medical authority signed form.

DEFINITIONS*:

“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 activities, 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” are functions such as caring for one’s self, performing manual tasks, walking, seeing,

hearing, speaking, breathing, learning, and working.

“Has a record of such an impairment” is defined as having a history of, or have been classified (or misclassified) as

having a mental or physical impairment that substantially limits one or more major life activities.