SY RE: Special Diet Form. Dear Parent:

Transcripción

1 San Antonio Independent School District 2 Haven for Hope Way San Antonio, Texas Telephone (210) Fax (210) Food & Child Nutrition Services BOARD OF EDUCATION SY RE: Special Diet Form Dear Parent: JAMES HOWARD President CARLOS VILLARREAL Vice President ADELA R. SEGOVIA Secretary OLGA M. HERNANDEZ Asst. Secretary RUBÉN D. CUERO ED GARZA PATTI RADLE DR. ROBERT J. DURÓN Superintendent According to the National School Lunch Program Act, the Food and Child Nutrition Services (FCNS) Department is required to adhere to specific regulations to accommodate special diets for students enrolled in the San Antonio Independent School District. Special diet requests will be reviewed and evaluated on a case-by-case basis. Generally, children with food allergies or intolerances do not have a disability as defined in any of the Acts or laws, and the school food service may, but is not required to, make food substitutions for them. However, when food allergies result in severe, life-threatening (anaphylactic) reactions, the child s condition would meet the definition of disability and the substitutions prescribed by a medical authority (Physician) must be made. The San Antonio Independent School District (SAISD) provides this dietary information as a courtesy. Neither SAISD nor any joint providers of the data make warranties of any kind, whether expressed or implied, for the information provided. The District specifically disclaims responsibility for the accuracy or quality of information obtained through Internet connections or through its vendors. The information is for informational purposes only and not intended to constitute professional or medical advice. Revised May

2 San Antonio Independent School District 2 Haven for Hope Way San Antonio, Texas Telephone (210) Fax (210) Food & Child Nutrition Services BOARD OF EDUCATION SY RE: Formulario para Dieta Especial Estimado Padre de Familia: JAMES HOWARD President CARLOS VILLARREAL Vice President ADELA R. SEGOVIA Secretary OLGA M. HERNANDEZ Asst. Secretary RUBÉN D. CUERO ED GARZA PATTI RADLE DR. ROBERT J. DURÓN Superintendent Según la ley del Programa de Almuerzos Escolares, el Departamento de Servicios de Comida y Nutrición para el Niño está obligado a adherirse a normas especificas para dietas especiales de estudiantes matriculados en el Distrito Escolar Independiente de San Antonio. Las peticiones para dieta especial serán revisadas y evaluadas individualmente basadas en cada caso. Por lo general, los niños con alergias ó intolerancia a ciertos alimentos, no se consideran como niños discapacitados según la ley. Por lo tanto, las escuelas del Departamento de Nutrición pueden, pero no se les requiere preparar comidas especiales para sustituir los alimentos de estos niños. Sin embargo, cuando la alergias tienen resultados graves que amenazan la vida del niño con reacción anafiláctica, entonces esta condición se define como discapacidad y debe ser reconocida por un médico y una recomendación debe ser sometida. El Distrito Escolar Independiente de San Antonio (SAISD) proporciona la información dietética como una cortesía. SAISD ni cualquier proveedor de conjuntos de datos que garantías de ningún tipo, ya sea expresa o implícita, la información proporcionada. El Distrito específicamente exime de responsabilidad por la exactitud ni la calidad de la información obtenida a través de conexiones de Internet o de sus proveedores. La información es para propósitos de información solamente y no pretende constituir asesoramiento profesional o médico. Revised May

3 San Antonio Independent School District Food & Child Nutrition Services (FCNS) & Head Start Program Diet Prescription for Meals at School 2 Haven for Hope Way, San Antonio, Texas Phone: (210) Fax: (210) FS160 (Rev. May 2011) School Year Student s Legal Name: Date of Birth: Student ID: School Attending: Grade (Sept 2011): Date of Admissions, Review, & Dismissal (ARD) Meeting/Section 504 meeting: (Parents please include an FCNS nutrition professional in the ARD/504 meeting at the school at least 1x/year.) Parents: please read these instructions carefully - This required form is to be used by medical professionals to indicate whether a special diet or food modification is warranted for an SAISD student. A new form is required yearly. Special diet requests will be reviewed and evaluated on a case-by-case basis by FCNS Nutrition Professionals as per Federal/State requirements. The FCNS staff will make every attempt to reasonably accommodate students that have dietary restrictions that are not life threatening or reported by a physician as a disability. In the case of milk or lactose intolerance, a lactose free milk or USDA approved soy milk will be given as an option. Fruit juice or water can no longer be substituted in some meals (please see the Use of Non-Dairy Substitute Statement attached to this packet). The statement of disability must include: The nature of the disability and the reason the disability prevents the child from eating the regular school meal. The major life activity affected by the disability. Under Section 504 of the Rehabilitation Act of 1973, the Americans w/ Disabilities Act (ADA), and the ADA Amendments Act of 2008, a person with a disability is any person who has a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment or is regarded as having such an impairment. Must list the specific food(s) to be omitted from the child s diet. To be Completed by a Licensed Physician only 1. Condition/Diagnosis that requires a special diet or food modification at school: 2. Does this student have a disability? Yes No 3. If yes, describe the major life activities that are affected by the disability: 4. Please specify the diet order (See back for additional guidance) Licensed Physician (Print): Licensed Physician Signature: Registered Dietitian working w/case: Date: Phone: Phone:

4 Page 2 continued Name of Student: MILK/LACTOSE INTOLERANCE : Yes No NA (see the Use of Non-Dairy Subsitute statement) Can be completed by a Licensed Medical Authority (Physician s Assistant, Nurse Practitioner or Medical Physician) Signature Medical Authority Office Phone Number Date MUST BE COMPLETED BY A LICENSED PHYSICIAN MARK ONLY THOSE THAT APPLY TO THIS STUDENT A. TEXTURE MODIFICATION : Chopped/bite size pieces Finely ground Pureed Soft B. NUTRITION SUPPLEMENT REQUIRED Formula name To be administered (specify time & quantity) C. FOOD ALLERGIES submit an allergy profile if possible Peanut/Tree Nut allergy Milk/Dairy allergy (NOT LACTOSE INTOLERANCE) Milk/Dairy allergy (NOT LACTOSE INTOLERANCE) including cheese and products made with dairy such as milk in baked products or entrées Wheat (most of FCNS food items contain wheat parent is encouraged to (1) select menu items the student may consume by circling the items and (2) submit menu selections to FCNS Nutrition Professionals) Soy (most FCNS food items contain soy-parent is encouraged to (1) select menu items the student may consume by circling the item and (2) submit menu selections to FCNS Nutrition Professionals) Whole Egg Egg products in food (such as in baked items, entrées, mayonnaise), etc. Fish Other PARENT/GUARDIAN: Some substitutions may not be available or allowed. A meeting with the FCNS Nutrition Professionals may be needed for additional clarification. Under no circumstances are Food and Child Nutrition Services Staff allowed to revise or change a diet prescription or medical order. A copy of the menu is available at the schools and online ( I understand that if my child s medical or health needs change, it is my responsibility to notify the school office and also have the physician complete a new Diet Prescription for Meals at School form. Parent/Guardian s Signature Date Home Phone Number Parent/Guardian s Printed Name Parent/Guardian s Address FOR SAISD FCNS ONLY Date Received: Reviewed by: Comments: ARD/504 Meeting: Nondiscrimination Statement: In accordance with Federal Law and the U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer.

5 Use of NON- DAIRY MILK SUBSTITUTES: In response to a recent policy change by the United States Department of Agriculture (USDA), the San Antonio Independent School District Food & Child Nutrition Services Department (SAISD FCNS Dept.) is modifying its practice of offering substitute beverages to students who cannot consume fluid cow s milk. Prior to the policy change, the SAISD FCNS Dept. could substitute a beverage such as water or juice in place of milk, but the revised policy from USDA PROHIBITS such substitutions. The revised policy states that all beverages used as substitutes for cow s milk must match the nutritional profile and content of fluid cow s milk. Therefore in accordance with the policy change, the SAISD FCNS Dept. will offer soy milk as a non-dairy milk substitute for those students whose documented medical condition does not allow the consumption of cow s milk at: Breakfast and Lunch at the early childhood schools Breakfast at Breakfast in the Classroom elementary schools Students participating in the aforementioned meal programs do not have the option of declining menu items. Therefore, if soy milk were not offered to these specific students, they would be required to take fluid cow s milk to count as a reimbursable meal. Students at all other schools - middle and high school - are permitted to decline several items on the menu including fluid cow s milk, therefore, soy milk will not be offered to students during these meal periods, unless otherwise requested. Parents are encouraged to send a beverage from home if they chose to. USDA regulations require school districts to serve medically prescribed meals only to students with disabilities. The SAISD Food and Child Nutrition Services Department will continue to provide medically prescribed meals to the students of our district who would otherwise not receive individually adjusted meal plans. All special diet cases will be reviewed and evaluated on a case-by case basis by Registered Dietitians & other nutrition professionals. Please call our office if you have further questions at (taken in part from USDA Memo Code SP Q&A s: Milk Substitution for Children with medical or special dietary needs) Revised May

6 SUBSTITUTOS DE LECHE NO-LÁCTEA: En respuesta a un cambio reciente en la política por el Departamento de Agricultura de Estados Unidos (USDA), el Distrito Escolar Independiente de San Antonio y el Departamento Food & Child Nutrition Services modificarán su práctica de ofrecimiento de bebidas suplentes a los niños quienes no pueden consumir la leche de vaca líquida. Antes del cambio de política, el Departamento Food & Child Nutrition Services podía sustituir la leche con otra bebida como el agua o jugo, pero la revisión de la política de USDA PROHIBE tales sustituciones. La revisión declara que todas las bebidas utilizadas como suplentes a la leche de vaca deben igualar el perfil y el contenido nutricional de la leche de vaca liquida. Por lo tanto, de acuerdo con el cambio de política, el Departamento Food and Child Nutrition Services del Distrito Escolar de San Antonio ofrecerá la leche de soya como sustituto no lácteo de leche para esos niños cuya condición médica documentada no les permite el consumo de leche de vaca durante el: Desayuno y almuerzo en los centros preescolares Desayuno en las escuelas que ofrecen el programa de Desayuno en los Salones Los estudiantes que participan en los programas de comidas antes mencionados no tienen la opción de rechazar los artículos del menú. Por lo tanto, si la leche de soya no fue ofrecida a estos estudiantes, serán requeridos a tomar leche de vaca liquida para contar como comida reembolsable. Los estudiantes en las otras escuelas secundarias y preparatorias- se les permite rechazar varios artículos en el menú inclusive la leche de vaca liquida, por lo tanto, la leche de soya no será ofrecida a estudiantes durante estos periodos de comida, a menos que sea solicitada. Se permite que los padres envíen otro tipo de bebida si ellos lo desean. El reglamento de USDA requiere que los distritos escolares sirvan las comidas médicamente prescritas solamente a los estudiantes con discapacidades. El Departamento Food and Child Nutrition Services continuará proporcionando las comidas médicamente prescritas a los estudiantes en nuestro distrito que de otro modo no recibirían bajo un plan de comida individualmente ajustado. Los casos especiales serán revisados y evaluados caso-por-caso por Bromatólogos Registrados y otros Nutriólogos profesionales. Si tiene cualquier pregunta llame a nuestra oficina al (Fuente: USDA Memo Code SP Q&A s: Milk Substitution for Children with medical or special dietary needs) Revised May