Medical Statement for Special Dietary Needs
A fillable form for requesting special dietary accommodations that can be completed electronically or printed and filled out by hand. This form provides guidance and documentation for special dietary requests.
Special Dietary Needs Example Policy

The School Nutrition Team has created an example Special Dietary Needs policy that can be used at your school or district. Please note, this template should be thoroughly reviewed and modified to fit the needs of your school or district. All highlighted areas are meant to be filled in to reflect your school(s) or district.
Fluid Milk Substitutions

School Food Authorities (SFAs) may offer students a fluid milk substitute that is nutritionally equivalent to cow's milk without a signed medical statement. If your SFA would like to offer a fluid milk substitute to your students, please complete and submit the approval form below.
Guidance
- Special dietary needs rules and carbohydrate counting for students with diabetes participating in the USDA Child Nutrition Programs (Update to SNT Memorandum dated March 19, 2015) DPI SNT, 11/28/17
- Accommodating Children with Disabilities in the School Meal Programs: Guidance for School Food Service Professionals USDA, 07/25/17
- Accommodating Disabilities in the School Meal Programs: Guidance and Questions and Answers SP 26-2017, USDA, 04/25/17
- Modifications to Accommodate Disabilities in the School Meal Programs SP 59-2016, USDA, 09/27/16
- Q&As: Milk Substitution for Children with Medical or Special Dietary Needs (Non-Disability) SP 07-2010, USDA, 11/12/09
Training & Resources
- Webcast: Special Dietary Needs
- Webcast: Carbohydrate Counting for Students with Special Dietary Needs DPI, 06/13/16
- Special Dietary Needs Flowchart - DPI
- The Food Allergy Book: What Employees Need to Know - National Education Association Health Information Network
- Managing Food Allergies in Schools Toolkit - Centers for Disease Control and Prevention
- Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs - Centers for Disease Control and Prevention
- The first national comprehensive guidelines for school food allergy management (2013)