dietary restriction/food allergy form - Lake Havasu Unified School ...

Dietary Restriction/Food Allergy Report Form
Lake Havasu Unified School District #1
Student’s Name
PART A
Age
Name of School Grade Level Classroom
Does the child have a disability If Yes, describe the major life activities affected by the
disability.
Yes
No
Does the child have special nutritional or feeding needs If Yes, complete Part B of this
form and have it signed by a licensed physician.
Yes No
If the child is not disabled, does the child have special nutritional or feeding needs If Yes No
Yes, complete Part B of this form and have it signed by a recognized medical authority.
If the child does not require special meals, the parent can sign at the bottom and return the form to the school food
service.
PART B
List any dietary restrictions or special diet.
List any allergies or food intolerances to avoid.
List foods to be substituted.
List foods that need the following change in texture. If all foods need to be prepared in this manner, indicate “All.”
Cut up or chopped into bite size pieces:
Finely ground:
Pureed:
List any special equipment or utensils that are needed.
Indicate any other comments about the child’s eating or feeding patterns.
Parent’s Signature
Date:
Physician or Medical Authority’s Signature
Date:

INFORMATION CARD (dietary restrictions/food allergies)
Student’s Name
Teacher’s Name
Special Diet or Dietary Restrictions
Food Allergies or Intolerances
Food Substitutions
Foods Requiring Texture Modifications:
Chopped:
Finely Ground:
Pureed or Blended:
Other Diet Modifications:
Feeding Techniques
Supplemental Feedings
Physician or Medical Authority:
Name
Telephone
Fax
Additional Contact:
Name
Additional Contact:
Name
Telephone
Fax
School Food Service Representative/Person Completing Form:
Title
Telephone
Fax
Signature
Date:

Physician's Statement for Children with Disabilities
USDA regulations 7 CFR Part 15b require substitutions or modifications in school meals
for children whose disabilities restrict their diets. A child with a disability must be
provided substitutions in foods when that need is supported by a statement signed by a
licensed physician. The physician's statement must identify:
1. The child’s disability.
2. An explanation of why the disability restricts the child’s diet.
3. The major life activity affected by the disability.
4. The food or foods to be omitted from the child’s diet.
5. The food or choice of foods that must be substituted.
In Cases of Food Allergy
Generally, children with food allergies or intolerances do not have a disability as defined
under either Section 504 of the Rehabilitation Act or Part B of IDEA, and the school food
service may, but is not required to, make food substitutions for them.
However, when in the licensed physician's assessment, food allergies may result in
severe, life-threatening (anaphylactic) reactions, the child's condition would meet the
definition of "disability," and the substitutions prescribed by the licensed physician must
be made.
Medical Statement for Children with Special Dietary Needs
Each special dietary request must be supported by a statement, which explains the food
substitution that is requested. It must be signed by a recognized medical authority.
The medical statement must include:
1. An identification of the medical or other special dietary condition which restricts
the child’s diet.
2. The food or foods to be omitted from the child’s diet.
3. The food or choice of foods to be substituted.

Food Allergy Policy
1. ARAMARK is committed to providing a safe and pleasant dining experience for our customers. We
rely on our food manufacturers and processors ingredient listings, and the reliability of our
manufacturers and processors is a key component of ARAMARK’s overall approach to food quality
and safety, including dealing with allergens. However, we are not allergy experts and therefore
cannot give medical advice regarding food-related allergies.
2. All customer questions relating to the ingredients or content of any food are to be referred to the
manager on duty. Remember, in responding to such questions we must be as accurate and
complete as we can. No one should guess at the content of any food. If we do not know what the
ingredients are in a certain food item, then we need to tell the inquiring customer.
3. Because we must rely on food manufacturers’ and processors’ ingredient listings, we may not be
aware of ingredients which are actually in the food but not listed on the container or packaging.
4. If a customer identifies a severe allergy and there is any question about the ingredients of a food
item, encourage the customer not to consume that food item, and encourage the customer to select
one or more different items. Be sure to point out those alternative items to the customer.
5. If a customer displays a reaction which may indicate a food allergy, CALL 911 IMMEDIATELY.
Also contact the client’s security or health department, if appropriate.
6. Remember that we are not medically trained or otherwise qualified to provide allergy counseling. If
a client provides information about customer allergies or requests that our personnel meet with a
customer to address potential allergy problems, we will provide basic food content information to
enable the customer to make his or her determination about what to eat or not eat. However, each
client and customer must be advised that the ultimate responsibility for the customer’s safety rests
with that customer.
7. If you have any questions at any time about this policy contact your Safety and Loss Prevention
Manager.
8. All location opening packages should contain a copy of the pamphlet “Understanding Food Allergy”
published by the International Food Information Council Foundation (IFIC) and the American
Academy of Allergy, Asthma and Immunology. Single copies are available at no cost from IFIC. To
order, visit http://www.ific.org/publications/orderform.cfm. If additional IFIC pamphlets or other
materials are necessary or appropriate, then they should be obtained from the IFIC. If the IFIC
requires payment for the pamphlets or other materials, then payment should be made. ARAMARK
should not be making copies of IFIC pamphlets or other materials.
9. Any material made available at the IFIC website for downloading should meet the attribution
requirements specified at the IFIC website, at (http://www.ific.org/publications).
10. All locations MUST post in the kitchen the IFIC/NRA “FOOD ALLERGY” poster in English and
Spanish if appropriate (Spanish is on the reverse side of English). Order your poster using the
Publications Request Format: http://www.ific.org/publications/upload/Oct2004pubslist.pdf.