MEDICALSTATEMENTTOREQUESTSPECIAL MEALSAND/ORACCOMMODATIONS
1. SPONSORName / 2. SiteName, if different from#1. / 3.SiteTelephoneNumber4.NameofParticipant / 5.Dateof Birth
6.NameofParent orGuardian / 7. TelephoneNumber
8.CheckOne:
Participanthasadisabilityoramedicalconditionandrequiresaspecialmealoraccommodation.(Referto instructions.)CACFP,schoolsandagenciesparticipatinginfederalnutritionprogramsmustcomplywithrequests forspecialmealsandanyadaptiveequipment.Alicensedphysicianmustsignthis form.
Participantdoesnothaveadisability,butis requestingaspecialmealoraccommodationduetofoodintolerance(s) orother medicalreasons.Foodpreferencesarenotanappropriateuseof thisform.CACFP,schoolsandagenciesparticipatinginfederalnutritionprogramsareencouragedtoaccommodatereasonablerequests.Alicensedphysician,physician’sassistant,ornursepractitionermustsignthisform.
Participantdoesnothaveadisability,butis requestingaspecialaccommodationforafluidmilksubstitutethat meetsthenutrientstandardsfornon-dairybeveragesofferedasmilksubstitutes.Foodpreferencesarenotan appropriateuseof thisform.CACFP,schoolsandagenciesparticipatinginfederalnutritionprogramsare encouragedtoaccommodatereasonablerequests.Alicensedphysician,physician’sassistant,nurse practitionerorparentorguardianmaysignthisform.
9.Disabilityor medical conditionrequiringaspecial meal oraccommodation:
10.Ifparticipant hasadisability,providea brief descriptionof participant’smajorlifeactivityaffectedbythedisability:
11.Dietprescriptionand/oraccommodation:(pleasedescribeindetail to ensureproper implementation-useextrapagesasneeded)
12.Foodstobeomittedandsubstitutions: (pleaselist specificfoodstobe omittedandrequiredsubstitution;attachasheetwith
additional informationasneeded)
A. FoodsToBeOmittedB.FoodstobeSubstituted
13. Indicatetexture:
RegularChoppedGroundPureed
14.Adaptive Equipment:
15.SignatureofPreparer* / 16.Printed Name / 17.TelephoneNumber / 18.Date
19.SignatureofMedicalAuthority* / 20.Printed Name / 21.TelephoneNumber / 22.Date
* Physician’s signature is required for participants with a disability. For participants without a disability, a licensed physician, physician’sassistant,ornursepractitionermust signtheform. Parent/legalguardiansignatureisacceptable forfluidmilksubstitution forachildwithspecial medical ordietaryneeds otherthanadisability. Theinformationon thisform should beupdated to reflect the currentmedicaland/ornutritionalneedsof theparticipant.
InaccordancewithFederalcivilrightslawandU.S.DepartmentofAgriculture(USDA)civilrights regulationsandpolicies,theUSDA,itsAgencies,offices,andemployees,andinstitutions participatinginoradministering USDAprogramsareprohibitedfromdiscriminatingbasedonrace, color,nationalorigin,sex,disability,age,orreprisalorretaliationforpriorcivilrightsactivityinany programoractivityconductedorfundedbyUSDA.
Personswithdisabilitieswhorequirealternativemeansofcommunicationforprograminformation (e.g.Braille,largeprint,audiotape,AmericanSignLanguage,etc.),shouldcontacttheAgency(State orlocal)wheretheyappliedforbenefits. Individualswhoaredeaf,hardofhearingorhavespeech disabilitiesmaycontactUSDAthroughtheFederalRelayServiceat(800)877-8339. Additionally, programinformationmaybemadeavailableinlanguagesotherthanEnglish.
Tofileaprogram complaint ofdiscrimination,complete theUSDA ProgramDiscrimination Complaint Form,(AD-3027)foundonlineat: addressed toUSDAandprovideintheletteralloftheinformationrequestedintheform.
Torequest acopyofthecomplaintform,call(866)632-9992.SubmityourcompletedformorlettertoUSDA by:
(1)mail:U.S.DepartmentofAgriculture
OfficeoftheAssistantSecretaryforCivilRights
1400IndependenceAvenue,
SW Washington,D.C.20250-9410;
(2)fax:(202)690-7442;or
(3)email:.
Thisinstitution isanequalopportunityprovider.
This statement implementation date is November 2015.
CACFP-227Revised6-2014
MISSOURIDEPARTMENTOFHEALTH AND SENIOR SERVICES COMMUNITYFOOD andNUTRITION ASSISTANCE
CHILD andADULTCARE FOOD PROGRAM
INSTRUCTIONS forCOMPLETINGCACFP-227
REQUESTforSPECIALMEALSAND/ORACCOMMODATIONS
1.Center/School/Agency:Printthenameof thecenter,schooloragencythat is providingtheform tothe parent/guardian.
2.Site:Printthenameof thesitewheremeals willbeserved(e.g.,childcarecenter,schoolsitecommunity center,etc.)
3.SiteTelephoneNumber:Printthetelephonenumberof sitewheremealwillbeserved.See#2.
4.NameofParticipant:Printthenameof thechildoradultparticipantto whomtheinformationpertains.
5.AgeofParticipant:PrinttheparticipantDateof Birth.
6.NameofParentorGuardian:Printthenameof thepersonrequestingtheparticipant’smedicalstatement.
7.TelephoneNumber:Printthetelephonenumberof parentorguardian.
8.CheckOne:Check()aboxto indicatewhetherparticipanthasadisabilityordoesnothaveadisability.
9.DisabilityorMedicalConditionRequiringaSpecialMealorAccommodation: Describethemedical conditionthatrequiresaspecialmealoraccommodation(e.g.,juvenilediabetes,peanutallergy,etc.)
10. If ParticipanthasaDisability,ProvideaBriefDescriptionofParticipant’sMajorLife Activity Affected bytheDisability:Describehowphysicalormedicalconditionaffectsdisability.Forexample:”Allergyto peanutscausesalife-threateningreactionaffectingtherespiratorysystem.”
11. DietPrescriptionand/orAccommodation: Describeaspecificdietoraccommodationthathasbeen prescribedbyaphysician,ordescribedietmodificationrequestedforanon-disablingcondition.For example: ”Allfoodsmustbeeitherin liquidorpureedform.Participantcannotconsumeanysolidfoods.”
12. IndicateTexture: Check()aboxto indicatethetypeof textureof foodthat is required.Iftheparticipant doesnotneedanymodification,check“Regular”.
13. A. FoodstoBeOmitted: Listspecificfoodsthatmustbeomitted.For example,“excludefluidmilk.”
B. FoodstoBeSubstituted:Listspecificfoodstoincludein thediet.Forexample,“calciumfortified juice.”
14. AdaptiveEquipment:Describespecificequipmentrequiredtoassisttheparticipantwithdining.(Examples mayincludea“sippy”cup,alargehandledspoon,wheel-chairaccessiblefurniture,etc.)
15SignatureofPreparer:Signatureof personcompletingform.
16. PrintedName:Printnameof personcompletingform.
17. TelephoneNumber:Telephonenumberof personcompletingform.
18. Date: Datepreparersignedform.
19. SignatureofMedical Authority: Signatureof medicalauthorityrequestingthespecialmealor accommodation.
20. PrintedName: Printnameof medicalauthority.
21. TelephoneNumber: Telephonenumberofmedicalauthority.
22. Date: Datemedicalauthoritysignedform.
TheAmericanwithDisabilitiesAct AmendmentActdefinesa “disability,”inpart,asaphysicalormental impairmentthatsubstantiallylimitsamajorlifeactivityormajorbodilyfunctionof anindividual.
(Foradditionalinformationonthedefinitionofdisability,pleaserefertoSection504oftheRehabilitation
Actof1973andtheAmericanswithDisabilitiesAct AmendmentsActof2008)
InformationregardingtheADAAA,whichexpandedthedefinitionofdisability,canbefoundat:
Formoreinformation,refertothesubjectinformationin the ProgramspecificPolicyand ProcedureManualat:
6-2014