Guide for Managing Special Dietary Needs in School Food Service Indiana Department of Education

Overview

All sponsors that participate in the U.S. Department of Agriculture (USDA) School Nutrition Programs must comply with the federal requirements for accommodating children with special dietary needs. The USDA school nutrition programs include the:

• National School Lunch Program (NSLP);
• School Breakfast Program (SBP);
• Afterschool Snack Program (ASSP);
• Seamless Summer Option (SSO);
• Summer Food Service Program (SFSP);
• Special Milk Program (SMP);
• Fresh Fruit and Vegetable Program (FFVP); and
• Child and Adult Care Food Program (CACFP).

This guide summarizes the federal laws and USDA policies that determine these requirements along with further information, details, and best practices from the Indiana Department of Education (IDOE).

Resources

The Indiana Department of Education (IDOE) has created a webpage that houses Indiana created resources, medical statement forms, cycle menus, and information from USDA. IDOE encourages sponsors to utilize, download, and review these resources for their programs to ensure that they have the information they need in order to operate the best program possible for their students.

Legislation

Federal nondiscrimination laws and regulations contain specifications that require schools and institutions to make reasonable meal modifications on a case-by-case basis for children who have a disability or impairment that limits and/or restricts their diet. Each piece of legislation builds upon the others to provide clarification and further information on how it affects the modifications needed for students with disabilities.

Section 504 of the Rehabilitation Act of 1973

Section 504 of the Rehabilitation Act of 1973 prohibits all programs and activities receiving federal financial assistance from discriminating against children with disabilities, as defined in the law. A “person with a disability” means 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. The USDA regulations for school nutrition programs (7 CFR 210.10(m) and 7 CFR 220.8(m)) require reasonable meal modifications for children whose disability restricts their diet, based on a written medical statement signed by state licensed healthcare professionals with prescriptive authority and registered dietitians. Meal modifications must be related to a child’s disabling condition.

Additionally, based on Section 504, all Local Educational Agencies (LEAs) who employ fifteen or more people in the entire organization (not just food service staff) are required to have a 504 Coordinator. This person ensures that someone is designated to coordinate compliance with disability requirements. Typically, this is not the food service director, but rather someone employed under special education, counseling, or other administrative position.

Section 504 Determinations

The determination of whether a child meets the disability standards under Section 504 is made through a meeting, which can be initiated by anyone. This meeting should be made up of those who participate equally in the decision-making process, including teaching, administrative, and other personnel staff. The group should assess the child’s data, determine if additional information is needed, and determine if the child qualifies as having a disability under Section 504. If the team determines that the child meets the Section 504 definition of a disability, a 504 Plan should be put into place, making sure all areas are covered where the disability may affect the child, such as through food service, transportation, and in the classroom. If the Section 504 meeting determines that the child does not have a disability, the sponsor could choose to accommodate the child, but would not be legally obligated to do so.

The team, which should be led by the 504 Coordinator may include, but is not limited to:

• Administrative representative(s)
• Coaches and physical education teachers
• Custodial staff
• Food service director/staff
• Parent/Guardian of student
• School counselor/Social worker/Guidance counselor(s)
• School/Facility health professional
• Teachers
• Transportation staff
• Other learning support staff and aides, based on the student's curriculum and activities

Developing a 504 Plan

When a sponsor receives notice that a student has a disability or impairment and meets the Section 504 standards for disabilities, a 504 Plan must be developed and implemented. The sponsor should compile and review the following information to see if any of it applies to the student. Any applicable information should be kept on file with the student's records.

• Individualized Health Care Plan (IHCP)
• Emergency Action Plan (EAP)
• Medical Statement Form
• Parent or guardian's signed consent to share information with other school staff
• If an epinephrine auto-injector is required
• All other necessary medications for the student during the school day
• For food allergies, a description of the student's past reactions, including triggers and warning signs for allergies
• Age-appropriate ways to include the student in planning for care/implementing the plan
• Individualized Education Program (IEP)
• *Note that additional information may be required

The sponsor must then make the modifications specified by the recognized medical authority in the child’s 504 Plan. Accommodations to address the child’s dietary needs should be written into a 504 Plan. A separate Individualized Health Care Plan (IHCP) may be written for the child. In some situations, the IHCP is the child’s 504 Plan.

Some students may not have a 504 Plan but may instead have an Individualized Education Program (IEP). If dietary needs interfere with the child’s ability to benefit from instruction, a plan to address the child’s special dietary needs can be considered a related service included in the IEP. The sponsor must make the meal modifications indicated in the IEP. The IEP may contain goals and objectives directly related to the child’s dietary needs, such as feeding goals. In the related service area, the IEP may indicate what the child needs when the special dietary needs are considered. In addition, the modifications and accommodations page of the IEP document should indicate any meal modifications for the child. Services that are necessary to enable the child to benefit from instruction must be written as a related service for the child.

If a child is not eligible for special education nor qualifies under Section 504, school nurses may choose to write an IHCP to address the child’s nutrition needs.

Americans with Disabilities Act (ADA) and the ADA Amendments Act (ADAAA)

The Americans with Disabilities Act (ADA) was signed into law on July 26, 1990, by President George H.W. Bush. The ADA is one of America's most comprehensive pieces of civil rights legislation that prohibits discrimination and guarantees that people with disabilities have the same opportunities as everyone else. This legislation extended the Section 504 requirements into the private sector. To be protected by the ADA, one must have a disability, which is defined by the ADA as a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment. The ADA definition of a disability is almost identical to the Section 504 definition. The ADA also provides a definition of what “substantially limits” (42 U.S.C. § 12101 et seq.; 29 C.F.R. § 1630 et seq.) entails.

The Americans with Disabilities Act Amendments Act (ADAAA) made significant changes to the ADA’s definition of disability by broadening what qualifies as a "disability" and limiting consideration of the corrective effects of alleviating measures (i.e., medication or learned behavioral modifications). The final rule (28 CFR Parts 35 and 36) for the ADAAA includes a list with examples of diseases and conditions that may qualify an individual for protection under Section 504 or ADA including, but not limited to orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, cancer, heart disease, diabetes, intellectual disability, emotional illness, Attention Deficit Hyperactivity Disorder (ADHD), and Human Immunodeficiency Virus (HIV) infection (whether symptomatic or asymptomatic). The ADAAA specifically prohibits an “alleviating measure” from being used to deny an individual with a disability protection under Section 504. For example, if a child’s diabetes can be controlled through insulin and diet, the child may still qualify for protection because the alleviating measures (insulin) cannot be considered in determining qualification.

The ADAAA also overturned a series of U.S. Supreme Court decisions that interpreted the Americans with Disabilities Act in a way that made it difficult to prove that impairments were a disability. These amendments to the ADA made it easier for a person with food allergies, intolerances, and other food related disabilities to qualify for protection under the ADA.

Individuals with Disabilities Education Act (IDEA)

Schools are required to provide special education and related services to students who are covered by the Individuals with Disabilities Education Act (IDEA). The related services covered within IDEA could include nutrition services. IDEA is different from the ADA and Section 504, because it relates to the accommodations a sponsor must make in the individualized education and curriculum of a student with a disability, not just the ability of the student to attend school classes and activities with other students.

A qualifying disability under IDEA is different than the term disability under Section 504. Under IDEA, a student with a disability means the student was evaluated in accordance with IDEA, has one or more of the recognized thirteen disability categories, and because of the qualifying disability requires special education and related services. The disability categories include Autism spectrum disorder, blind or low vision, intellectual disability, deaf or hard of hearing, deaf-blind, developmental delay (early childhood), emotional disability, language or speech impairment, multiple disabilities, other health impairment, orthopedic impairment, specific learning disability, and traumatic brain injury.

When a student qualifies for special education and related services under IDEA, schools must develop an Individualized Education Program (IEP) for the student. An IEP is a written plan for a student with a disability that is developed, reviewed, and revised in accordance with IDEA and the U.S. Dept. of Education’s implementing regulations. Typically, students with food allergies are accommodated through an Emergency Action Plan (EAP), an Individual Health Care Plan (IHCP) and/or Section 504 Plan and not an IEP. You may however have students with mental impairments or physical disabilities that have nutrition service requirements or accommodations included within their IEP.

School Nutrition Programs Regulations

The USDA nondiscrimination regulations (7 CFR 15b.3) and regulations for school nutrition programs (7 CFR 210.10(m) and 7 CFR 220.8(m)) require that sponsors make modifications on a case-by-case basis for children whose disability restricts their diet. The definition of what would be considered a disability comes from the definitions in Section 504 of the Rehabilitation Act and the Americans with Disabilities Act and the Amendments Act.

Based on guidance within USDA Memo SP 59-201: Policy Memorandum on Modifications to Accommodate Disabilities in the School Meal Programs, sponsors must offer a reasonable modification that effectively accommodates the child’s disability and provides equal opportunity to participate in or benefit from the program. A “reasonable modification” is a change or alteration in policies, practices, and/or procedures to accommodate a disability that ensures children with disabilities have equal opportunity to participate in or benefit from a program. Meal modifications must be related to the disability or limitations caused by the disability, and require a medical statement from state licensed healthcare professionals and registered dietitians. A state licensed healthcare professional is defined as anyone with prescriptive authority in the state of Indiana, such as physicians, physician assistants, doctors of osteopathy, and advanced practice registered nurses (APRNs), i.e., nurse practitioners, clinical nurse specialists, and certified nurse anesthetists who are licensed as APRNs. Effective July 1, 2024, registered dietitians (RDs) are also able to sign a medical statement. Medical statements from RDs must be implemented by July 1, 2025, for school meal programs and October 1, 2025, for CACFP. The general guideline in making accommodations is that children with disabilities must be able to participate in and receive benefits from programs that are available to children without disabilities.

Office for Civil Rights Letters

The Office for Civil Rights (OCR) promotes and ensures that people have equal access and opportunity to participate in certain federally funded programs without facing unlawful discrimination. Two of OCR’s legal authorities include Section 504 and Title II of the ADA. At times, OCR provides letters, which can be used by school districts for guidance. These letters, however, are not published, but may be available where they have been submitted for publication in a private service or posted on an Internet site.

Requirements for Meal Modifications

The USDA regulations for school nutrition programs require that all meals served to children must comply with the meal patterns and nutrition standards. However, food substitutions and other reasonable modifications to the meal patterns may be necessary to meet the dietary needs of children who qualify as having a disability under any of the federal nondiscrimination laws. Examples of possible modifications include food restrictions, substitutions, texture changes (pureed, ground, chopped, or thickened liquids), increased or decreased calories, and tube feedings. Modifications to meal service may also include updating facilities or hiring adequate personnel in order to provide necessary services.

In certain situations, disability accommodations may require additional equipment; separate or designated storage or preparation areas, surfaces, or utensils; and specific staff training and expertise. For example, some children may require the physical assistance of a food service aide to consume their meal, while other children may need assistance tracking their dietary intake, such as carbohydrate intake for children with diabetes.

Non-Disability Related Accommodation Requests

The USDA regulations for school nutrition programs (7 CFR 210.10(m) and 7 CFR 220.8(m)) allow, but do not require, meal modifications for children whose special dietary needs do not constitute a disability, including those related to religious or moral convictions, general health concerns, and personal food preferences, such as a preference that a child eats a gluten-free diet because a parent believes it is better for the child. Sponsors may choose to make these accommodations, but are not required to do so. When making an accommodation for a religious or lifestyle choice, sponsors still must meet the meal pattern requirements for the student. If a sponsor elects to make substitutions for one student, the same accommodation should be made for all students.

For example, the sponsor decides to modify meals for religious purposes for an individual that cannot eat meat. Should any other child request a meal modification for a religious belief, then the sponsor would need to accommodate, as picking and choosing only specific requests would be discrimination. If there is a larger population in the school that would want vegetarian options, the school could choose to provide something on the menu daily in order to broadly accommodate many preferences. However, if implementing this option, the accommodation must fit within the meal pattern. If implementing offer versus serve, students can decline certain food components/items due to religious or moral convictions, general health concerns, and personal food preferences. For example, if implementing offer versus serve, students can choose to decline the milk due to religious or lifestyle choices.

While schools are not required to accommodate for religious and lifestyle choices, schools can menu plan and make the menu options available to everyone to help accommodate lifestyle and religious choices. For example, a school could have a fish option on Friday and make that available to everyone or offer one vegetarian meal on the menu daily.

Required Documentation for Meal Modifications

Sponsors should work to keep up-to-date and consistent documentation and forms for each student. USDA does not require a medical statement for children with disabilities if modified meals meet the meal pattern, such as meals modified only for texture. However, IDOE recommends obtaining a medical statement to ensure clear communication about the appropriate meal modifications for the child between parents or guardians, medical professionals, and applicable school staff. If a sponsor would like to have a medical statement, they may ask the household to provide this documentation but cannot delay implementation of the requested substitution until the form is received. The sponsor must accommodate the student as soon as possible.

For children with disabilities, modified meals that do not meet the meal patterns require a written medical statement signed by healthcare professional with prescriptive authority such as physician (MD or DO), nurse practitioner, or physician assistant and a registered dietitian. The medical statement must include:

• information about the child’s physical or mental impairment that is sufficient to allow the sponsor to understand how it restricts the child’s diet
• an explanation of what must be done to accommodate the child’s disability
• the food or foods to be omitted and recommended alternatives when necessary

Medical statements should provide sufficient information in order for sponsors to provide meals that are appropriate and safe for each child and that comply with the USDA requirements. For a template medical statement form, click the button below.

When necessary, sponsors should work with the medical professionals and/or child’s parent or guardian to obtain the required information. Sponsors cannot deny or delay a requested meal modification because the medical statement does not provide sufficient information. If the medical form does not fully explain the necessary modification, immediately contact the child’s parent or guardian for guidance. For example, if the medical statement does not provide recommended alternatives, the school still must serve the child a requested meal. Additionally, if indicated that a modification for a meal is needed, a sponsor cannot delay implementation until it receives a medical statement and must accommodate the student as soon as possible. If a medical statement is not immediately provided, the sponsor should document the initial interaction with the household and all attempts to contact the household regarding obtaining a medical statement.

Storage and Updates of Medical Statements

IDOE recommends storing medical statements in student’s health records maintained by the school nurse. The school nurse may share copies of student medical statements with school food service personnel for the purpose of meal modification for special dietary needs. Family Educational Rights and Privacy Act (FERPA) allows the sharing of confidential student information when there is a legitimate educational interest, such as making meal modifications for special dietary needs. The school food service department should have access to this information to make appropriate meal modifications for each child.

USDA requires sponsors to retain medical statements for three years, plus the current year. Updated medical statement forms each year are not required, however, when parents or guardians provide updated medical information, schools and institutions must ensure that medical statements on file reflect the current dietary needs of participating children. Changes to disability-related diet orders must be in writing and signed by a recognized medical authority.

Since children’s special dietary needs may change over time, IDOE strongly recommends that schools and institutions develop a plan for ensuring that dietary information is current. For example, a school’s policy could request an updated medical statement whenever a child has a physical, transitions to a different school, requires a new meal modification, or requires a change to an existing meal modification.

Procedures for Meal Modifications

The process of providing modified meals for children with disabilities should be as inclusive as possible. It is essential that school food service personnel work together with the child’s parent or guardian to ensure the child receives a safe meal and has an equal opportunity to participate in the school nutrition programs. USDA strongly encourages sponsors to utilize their Section 504 team to discuss best practices and develop a more holistic plan to create an overall safe environment for all children.

Using a team approach ensures information is shared consistently throughout the school environment and will help to protect children in situations where food is served outside of the cafeteria. Additionally, involving parents and guardians early in the process allows school employees to develop a rapport with the family, which prevents any miscommunication or misunderstanding about their child’s needs.

Communicating with Families

USDA regulation 7 CFR 15b.7 (a) require sponsors to notify families of the process for requesting meal modifications and the individual responsible for coordinating modifications. Methods of initial and continuing notification may include posting notices in relevant newsletters, bulletins, portions of the website, and other visual and auditory media. As part of this notification, sponsor should explain what constitutes a special dietary need, where parents and guardians need to submit supporting documentation for their child’s modification request, and the process that will ensue for making sure their child is accommodated.

When working with parents of children with special dietary needs for the first time and when a child first begins school, have patience and be willing to work out a plan with them as much as possible. What had worked so well in their own home is now being entrusted to unfamiliar people, so they may have additional questions for food service personnel. Often, the more information you can provide about your practices in the school and how the child will be accommodated, the smoother the process will be.

Parents concerned about a student’s dietary accommodations within the menu? Send a menu home for parents to circle options they know the student can have.

Creating a Special Dietary Needs Policy and Procedures

While not required, it is best practice for the sponsor to develop a special dietary needs policy. This policy should contain how the sponsor handles requests, including medically necessary requests in addition to religious and lifestyle requests. Additionally, information on the requirements for a medical statement form or prescription from medical authorities should be explained and how the process for acquiring these forms works for the sponsor. This would include that medical statement forms must contain information about the child’s physical or mental impairment that is sufficient to allow the sponsor to understand how it restricts the child’s diet, an explanation of what must be done to accommodate the child’s disability, and the food or foods to be omitted and recommended alternatives. It should also include that signatures must be from medical authorities with prescriptive capabilities, such as doctors (both MDs and DOs), physician assistants (PAs), or nurse practitioners (NPs) and registered dietitians (RDs).

For fluid milk allergies or intolerances, the sponsor can list a typical substitution or alternative within the policy. The standard operating procedures for the cafeteria and kitchen along with procedural safeguards should also be included. The policy cannot require a deadline or specific timeline for turning in a medical statement form. For instance, policies cannot state that accommodations will be suspended if a medical statement form is not received by a certain number of days. These policies should encourage consistent and correct communication between the sponsor, the student, and the parents or guardians to ensure that everyone is on the same page. See below for a template policy.

Declining a Request

If the meal modification request is related to a child’s disabling condition, it is almost never appropriate for the sponsor to decline a meal modification. The exception is a modification request that would fundamentally alter the nature of the school nutrition programs. This type of request, however is extremely rare. Sponsors should contact IDOE for assistance with any concerns that a requested modification would fundamentally alter the nature of the school nutrition programs, such as adding an entire program that the sponsor is not offering, like adding a breakfast program when not previously serving breakfast. Generally, the emphasis should be on working with parents or guardians to develop an effective approach for the child.

If the sponsor declines a meal modification request, they must ensure that the child’s parent or guardian understands their rights under the procedural safeguards process. Documentation will also be important for the sponsor. Make sure to keep documentation on file of what the request was from the family or doctor, why that could not be accommodated, and any modifications the sponsor offered in its place to the child.

Discontinuing a Request

If a child no longer needs a meal modification, it is not required for the sponsor to obtain written documentation from a recognized medical authority rescinding the original medical order prior to ending a meal modification. However, IDOE recommends that sponsors maintain documentation when ending a meal accommodation. For example, before ending the modification, the sponsor could ask the child’s parent or guardian to sign a statement indicating their child no longer needs a meal modification.

Communicating with School Staff

Close communication between school staff is vital to ensure a safe environment for students with special dietary needs. As previously mentioned with the 504 team, there are many individuals besides school food service staff that may be involved with the student's day-to-day actions, such as school health services staff, transportation staff, teaching staff, special education staff, school therapists, and other school faculty members. Consistent, clear communication between these staff members will help to make sure that any changes to the status of the medical information of the student is understood and implemented where necessary.

Sponsors must establish procedures for identifying children with special dietary needs and providing this information to the staff responsible for feeding children. For some conditions, such as food allergies, it may be appropriate for sponsors to maintain information for school food service personnel in the form of a list inside the serving or preparation areas of the kitchen identifying the children and the food restrictions, along with the appropriate substitutions designated by each child’s medical statement. This list would be adequate to document the substitutions in the USDA meal patterns if the school or institution has the original signed medical statements on file. It is important to keep in mind that this list should be kept out of public view, as to not violate civil rights rules.

Procedural Safeguards

USDA regulations (7 CFR 15b.25) require Local Education Agencies (LEAs) to establish a procedural safeguards process. This process provides information for parents and guardians regarding how to request a reasonable meal modification and their procedural rights for grievance procedures (7CFR 15b.6 (b))should they feel that reasonable accommodations are not being met for the child. This requirement can be fulfilled by using existing procedures that are in place for requests to accommodate students with disabilities in the classroom that are in compliance with Section 504 or IDEA. These procedures include the right to:

• file a grievance if they believe a violation has occurred regarding the request for a reasonable modification;
• receive a prompt and unbiased resolution of the grievance;
• request and participate in an impartial hearing to resolve their grievances;
• be represented by counsel at the hearing;
• examine the record; and
• receive notice of the final decision and a procedure for review, i.e., right to appeal the hearing’s decision.

If a grievance is filed, the individual processing the meal modification requests should not be the overseer of the grievance process. For example, the food service director has been processing and working on the meal accommodation, but the household decides to file a grievance because they feel their accommodation request has not been met. The food service director should not oversee the grievance process but should be involved and provide the grievance presider the necessary information about the situation, such as any documentation and communication made with the medical professionals and/or household.

In many cases, the Section 504 Coordinator is responsible for addressing requests for accommodations in the school in general, and may also be responsible for ensuring compliance with disability requirements related to meals and the meal service. Sponsors are not required to have a separate 504 Coordinator who is only responsible for meal modifications. However, school food service personnel should understand the procedures for handling requests for meal modifications and know how to contact the Section 504 Coordinator.

Remember: Requests must be reviewed on a case-by-case basis. Examples of conditions or disabilities that food service see that might require meal modifications include, but are not limited to autism; celiac disease; diabetes; food allergies; food intolerances, such as lactose intolerance and gluten intolerance; and metabolic disorders. These examples of medical conditions are not all-inclusive and may not require meal modifications for all children.

Meeting the Meal Pattern

Accommodations Within the Meal Pattern

If there is a medical need, disability, and/or impairment and the meal can be accommodated within the meal pattern (single food allergy, texture modifications, etc.), sponsors are not required to obtain a signed medical statement. If a sponsor would like to have a medical statement, they may ask the household to provide this documentation but cannot delay implementation of the meal accommodation. The sponsor must accommodate the student as soon as possible.

Whenever possible, it is encouraged for sponsors to offer children with disabilities a variety of options over the school week that is similar to the weekly variety offered to children without disabilities. In certain cases, a child may have a restricted diet that requires the same modified meal each day. However, most children will be able to eat a variety of modified meals over the week. Depending on the child’s individual medical condition and the recognized medical authority’s instructions, a reasonable modification could be offering the same modified meal that meets the child’s specific dietary needs each time the child eats school meals or having a cycle menu of modified meals that meet the child’s specific dietary needs, based on input from the child’s parent or guardian, medical professionals, school nurse, school dietitian, and other appropriate individuals.

Accommodations Outside of the Meal Pattern

If a student needs a substitute due to a medical need, disability, and/or impairment outside the meal pattern (multiple food allergies, tube feedings, etc.), sponsors need a medical statement signed by a state licensed healthcare professionals with prescriptive authority (physician, nurse practitioner, or physician assistant) and a registered dietitian. With this documentation, these meals are reimbursable. When the medical statement is required, it must include:

• information about the child's physical or mental impairment that is sufficient to allow the sponsor to understand how it restricts the child’s diet
• an explanation of what must be done to accommodate the child’s disability
• the food or foods to be omitted and recommended alternatives when necessary

A sponsor cannot delay implementation until it receives the medical statement and must accommodate the student as soon as possible. If a medical statement is not immediately provided, the sponsor must document the initial interaction with the household and should document all attempts to contact the household regarding obtaining a medical statement.

If a family requests that a student has juice, water, or a milk substitute not nutritionally equivalent to cow’s milk due to a medical need, disability, and/or impairment, sponsors must have a medical statement signed by a health care provider with prescriptive authority or a registered dietitian. With this medical statement, this makes the non-nutritionally equivalent beverage a part of a reimbursable meal for the child.

If a medical statement is needed because the accommodation is outside the meal pattern, the school cannot stop or discontinue the accommodation if they cannot get the necessary information from the household. Schools should document their multiple efforts and work with others such as the school nurse, principal, counselor, etc. to try and get the necessary information.

General Guidelines

Specific Brands of Food

Sponsors may consider expense and efficiency in choosing an appropriate approach to accommodate a child’s disability. Sponsors must offer a reasonable modification that effectively accommodates the child’s disability and provides equal opportunity to participate in or benefit from the school nutrition programs. Sponsors are generally not required to provide a specific brand of food, unless it is medically necessary. In most cases, a generic brand is sufficient. For example, a child’s medical statement for a food allergy might request a specific brand of bread as a substitute. The sponsor is generally not required to provide the requested brand but must offer to provide a substitute that does not contain the specific allergen(s) that affects the child.

In situations where the requested substitute is very expensive or difficult to procure or obtain, it is reasonable for the sponsor to follow up with the family to see if a different substitute would be safe and appropriate for the child. For example, if the medical statement lists a specific brand of gluten-free chicken patty, the sponsor could check with the family to see if it would be safe and appropriate to provide a different substitution. For example, appropriate substitutes might include:

• a different brand of gluten-free chicken patty
• gluten-free grilled or baked chicken
• another type of food that meets the child’s special dietary needs, e.g., gluten-free hamburger or sliced turkey.

Eating Areas

Federal civil rights legislation, including Section 504 of the Rehabilitation Act of 1973, IDEA, and Titles II and III of the ADA, requires that in providing nonacademic services, including meals, schools and institutions must ensure that children with disabilities participate along with children without disabilities to the maximum extent appropriate. This allows children to interact with and learn from other children with backgrounds different from their own.

However, under some circumstances it may be appropriate to require children with certain dietary needs to sit at a separate table. For example, if a child requires significant assistance from an aide to consume their meals, it may be necessary for the child and the aide to have more space during the meal service.

Additionally, sponsors may determine that a separate eating area would be best for children with severe food allergies. The separate eating area may be:

• a designated table in the cafeteria cleaned according to food safety guidelines (to eliminate possible cross contact of allergens on tables and seating); or
• an area away from the cafeteria where children can safely consume their meals.

Prior to developing a special seating arrangement, the school should determine, with input from the child’s family and physician, if this type of seating arrangement would truly be helpful for the child. If the school develops a special seating arrangement, other children should be permitted to join the child with the food allergy, provided they do not bring any foods that would be harmful to the child.

Schools and institutions cannot segregate children with disabilities from the regular meal service simply as a matter of convenience. In addition, it is not appropriate to simultaneously use a separate table to segregate children who are being punished for misconduct. In all cases, the decision to feed children with disabilities separately must always be based on what is appropriate to meet the needs of the children.

Nutrition Information

Requesting nutrition information for foods served in school meals is considered a reasonable meal modification. Sponsors should be prepared to provide nutrition information for school meals to students, families, school nurses, and others. For example, the sponsor can maintain a binder of nutrition labels in the school cafeteria or district food service office that parents or guardians can review. This enables families, in partnership with their medical professional, to determine the appropriate meals for their child’s specific dietary concerns. If a product’s label does not provide adequate information, it is the responsibility of the sponsor to obtain the information necessary to ensure a safe meal for the child. The sponsor should contact the product’s supplier or manufacturer to obtain the required information.

The sponsor is not necessarily required to provide nutrition information for all meals, since it would be very burdensome to provide this information. For example, if a child with diabetes must track their carbohydrate intake, the sponsor is not required to provide nutrition information for all food choices and combinations available during the lunch and/or breakfast meal service. A reasonable accommodation could be developing a cycle menu with input from the child’s parent or guardian, medical professionals, school nutritionist, school nurse, and other members of the Section 504 team, as appropriate. In this case, the sponsor would only be required to provide nutrition information for the foods on the planned cycle menu for the special diet but not all foods offered in the school nutrition programs.

It is important to maintain communication between the school, students, and families. When parents or guardians require nutrition information for school meals, IDOE recommends providing a monthly menu several weeks in advance. This enables parents or guardians to determine which meals their child will be eating. It also allows sufficient time for the school food service program to gather nutrition information for the selected meals to share with the student, parents or guardians, school nurse, and other appropriate personnel.

Nutrition Labels

It is imperative that school foodservice staff thoroughly reads the labels of all food and beverage items that enter the kitchen. Many food items contain hidden food allergens that could pose a risk to students. For example, some yogurts contain fish protein as a thickener and some hamburger patties can contain soy and/or wheat in them as well. All food item labels should be inspected as soon as deliveries are received and before being stored. Continuously check product labels, as manufacturers can change ingredients without warning. Only reviewing labels during the summer or at the start of the year, will not catch changes made later in the year.

Additionally, a sample label on a company website may not accurately reflect the actual ingredients of a food or beverage item that was delivered to the kitchen. Multiple vendors may supply USDA products (like fajita chicken), however, each manufacturer will have a unique product formulation, so while one company’s chicken may be soy-free, another’s may contain soy.

Vended Meals and Food Service Management Companies

Sponsors must always ensure that any benefits available to the general school population are equally available to children with disabilities. Consequently, sponsors must make accommodations for children with disabilities regardless of whether the school district operates the school nutrition program or contracts with a food service management company (FSMC), vendor, or co-op.

When a FSMC or co-op operates the school nutrition program or the sponsor obtains meals from a vendor, the sponsor must address the issue of meal modifications. IDOE recommends that the contract developed with the FSMC, co-op, or vendor specifies the sponsor’s requirements for meal modifications. Sponsors that do not have any need for meal modifications at the time a bid is prepared should still include sufficient information in the bid to ensure that the vendor is aware that meal modifications may be required any time during the term of the contract. The sponsor, not the FSMC, co-op, or vendor, is ultimately responsible for complying with USDA regulations for school meals, including meal modifications for children whose disability restricts their diet.

Example Wording for Vendor Contract --- The vendor will make substitutions for food and/or beverage components for students with special dietary needs at no additional cost to the student. This includes, but is not limited to, food allergies and/or intolerances, texture modifications, carbohydrate counts, and calorie modifications. Substitutions shall be made on a case-by-case basis. In order to reduce and/or prevent the possibility of allergens being present in food or beverage items, the vendor is required to allow access to all ingredient and nutrition labeling for all products. If accommodations are not met within the meal pattern, these changes should be supported by a signed statement from a recognized medical authority. The SFA is responsible for obtaining and maintaining any documentation required for the SFA to claim program reimbursements.

Fresh Fruit and Vegetable Program

Programs like the Fresh Fruit and Vegetable Program (FFVP) are still subject to special dietary needs rules and regulations. Schools that participate in this program should keep this in mind when ordering different produce for their students. If a child has a documented food allergy or intolerance, or other disability, then the school must make an accommodation for the child. For example, if a student has a medical statement form on file with a noted strawberry allergy, then the school must provide a fruit replacement for the student, such as grapes or orange wedges. Similarly, if a student has a medical statement form on file indicating that their food must be diced into small pieces due to a medical condition, then the school must provide that student's fruit or vegetable in accordance with these changes.

Pandemic and Emergency Plans

In the case of an emergency or an unexpected change in services, sponsors are not relieved of their obligation to provide meal accommodations and modifications to students with disabilities. This can often present unique challenges with uncertainty of meal service options. Sponsors should provide meals that meet the students' dietary needs and accommodations to the best of their ability. In order to ensure a smooth service, sponsors should outline a plan with the family for how the student's meals and accommodations may be affected and determine alternative options that can meet the student's needs. It is important to ensure that everyone is on the same page and stress that while the student may not receive the typical options, that the sponsor is striving to provide the most complete and nutritious meals to the student.

Food Safety

Food safety is an important part of maintaining a safe and healthy environment for all students to consume their meals. Proper understanding and employment of food safety is vital when working with food allergies or intolerances. For instance, preventing cross-contact is essential for maintaining a safe environment for students with food allergies and intolerances. Cross-contact is different than cross-contamination in that cross-contamination occurs when bacteria or other microorganisms are unintentionally transferred from one object to the next, whereas cross-contact is when an allergen is unintentionally transferred from one food to another. It is important to note as well, that proper cooking does not reduce or eliminate the chances of a food allergy reaction in the case of cross-contact. By not following proper procedures, students with food intolerances and allergies are at risk of a reaction. It is imperative that staff is regularly trained on both of these topics.

Below are important food safety criteria to follow:

• Develop Standard Operating Procedures (SOPs) by writing down the actual steps taken when performing the specific task. When using sample SOPs from organizations or other schools, be sure to customize the information, so it is specific to the local program.
• Always wash hands and change gloves when preparing different menu items.
• Use clean kitchen equipment or tools when preparing food. Your kitchen may even opt to have specific allergen-friendly tools that are used only on specific items. One way to designate specific tools would be to put colored tape on the tools that will not come in contact with an allergen, such as peanuts.
• Clean and sanitize surfaces between every menu item. This includes countertops, tabletops, cutting boards, flat-tops, etc.
• Be cognizant of hidden sources of cross-contact. For instance, wiping up splatter from batter, never touching condiment bottles directly on food, refrain from touching the same towel when preparing multiple food items, and being aware of circulating allergens in a convection oven.
• Work with teachers, parents, students, and other food service staff to ensure that perishable items, including those brought from home are stored safely and properly.
• Keep a watchful eye on food recalls that involve foods being exposed to allergens that are not listed as an ingredient.

Create food allergy friendly kitchen tools. Wrap the tools in a different colored tape to make them stand out against the other “regular” tools in the kitchen.

Finance

Price of Meals

The USDA requirements for meal modifications apply to all children regardless of their eligibility for paid, free, or reduced-price meals. The requirements for meal modifications are based on whether a child is determined to have a disability that restricts their diet, not whether the child is eligible for free or reduced-price meals. Prices of meals with modifications cannot change due to an increase in cost of items, service, etc.

Meal Reimbursement

Sponsors claim modified meals at the same reimbursement rate as regular meals that meet the USDA meal pattern. USDA considers any additional costs for modified meals to be allowable food service program costs, but additional reimbursement is not available.

Provision 2 or 3 and Community Eligibility Provision

Sponsors that participate in Provision 2 or 3 or Community Eligibility Provision (CEP) must accommodate students with special dietary needs just as sponsors who do not operate any of the provision programs. Students still receive their meal for free as all other students. Additionally, reimbursement remains the same for meals that require accommodations regardless of expense on the sponsor. As previously mentioned, the intention is that regardless of the student's disability status, they receive the same benefits and meal experience as all other students.

Allowable Costs

In most instances involving modified meals, the school food service account pays the cost of special food and food preparation equipment. School food service personnel will generally be responsible for providing the alternate meal. For example, if a child must have a pureed meal, it is reasonable to expect the school food service account to purchase a blender or food processor and to have the meal prepared by school food service personnel.

For delicate operations, such as tube feedings, proper administration generally requires the skills of specially trained personnel, such as nurses or specially trained aides who regularly work with the child. If the child has an IEP, special education funds may cover special labor costs. Without an IEP, these costs may be charged, as appropriate, to the food service account or may be assigned to the school district’s general fund or other funding sources. In most cases, meal modifications can be made with little extra expense or involvement, and the nonprofit school food service account can usually cover any additional expenses involved in making the modification.

Common Special Dietary Needs Modifications

Sponsors may receive a plethora of different meal modification requests. The different sections below will walk you through common requests sponsors may be asked, what they mean, what should be done to help accommodate the students, and resources for additional information on the disability.

Food Allergy

A food allergy reaction occurs when your body's immune system overreacts to a food or food substance that the body would otherwise consider harmless. The top 9 food allergens are eggs, milk/dairy, peanuts, tree nuts, fish, shellfish, wheat, soy, and sesame. Under the ADAAA, a food allergy does not need to be life-threatening or cause anaphylaxis to be considered a disability. A non-life-threatening food allergy may be considered a disability and require a meal modification if it impacts a major bodily function or other major life activity, such as digestion, respiration, immune response, and/or skin rash.

The sponsor must provide the child with a safe meal and a safe environment to consume the meal. School food service personnel must ensure that modified meals meet each child’s prescribed guidelines and are free of ingredients suspected of causing an allergic reaction. The sponsor must use proper storage, preparation, and cleaning techniques to prevent exposure to allergens through cross contact. The sponsor should develop a strategy or food allergy management plan for the daily management of food allergies for individual children. The sponsor can create a week’s worth of menus, such as a peanut free menu, and rotate that menu each week. Working with the household to see what foods the student typically eats is not required but recommended to create a menu that works for both the sponsor and household/student.

Sometimes, it is advisable to prepare a separate meal from scratch using ingredients allowed on the special diet, rather than serving a meal using processed foods. The general rule in these situations is to exercise caution at all times. If a food’s ingredients are unknown, the sponsor cannot serve the food to children who are at risk for allergic reactions.

Have emergency meal plans! Consider having a backup for students with special dietary needs or if you have a student who needs a dietary change as they are coming through the line. Having a back-up meal plan can help the kitchen stay calm under stress.

Food Intolerance

A food intolerance is an adverse food-induced reaction that involves a digestive system response rather than an immune system response. Under the ADAAA a food intolerance may be considered a disability if it substantially limits digestion, a bodily function that is a major life activity. For example, a child whose digestion is impaired by either a lactose or gluten intolerance may be a person with a disability, regardless of whether consuming milk or gluten-containing foods causes the child severe distress.

If there is a medical need, disability, and/or impairment, such as lactose intolerance, and a complete meal can be accommodated within the meal pattern, such as providing a milk substitute nutritionally equivalent to cow’s milk, sponsors are not required to obtain a medical statement signed by a state licensed healthcare professional with prescriptive authority or a registered dietitian. A written request from a parent/guardian would be acceptable. If a written request is not immediately provided, the sponsor must document the initial interaction with the household and should document all attempts to contact the household regarding obtaining a written request. If a sponsor would like to have a medical statement, they may ask the household to provide this documentation but cannot delay implementation of the requested substitution and must accommodate the student as soon as possible.

If the intolerance cannot be accommodated within the meal pattern, then the sponsor will need to obtain a medical statement signed by a state licensed healthcare professional with prescriptive authority or a registered dietitian that outlines what the medical need is and what replacements may be necessary.

In order to accommodate the student, the sponsor should work with the family to ensure that a complete menu is created as best as possible for the student. The sponsor can sponsor can create a week cycle menu that fits the student's needs for their food intolerance and rotate that menu each week.

Gluten-Free Diets

Gluten-free diets can be due to a gluten allergy or intolerance or due to Celiac disease. Celiac disease is an autoimmune, digestive disease that damages the small intestine and interferes with the absorption of nutrients from foods. Individuals with celiac disease cannot tolerate gluten, a protein found in wheat, rye, and barley. The treatment for celiac disease is to avoid all foods that contain gluten, including wheat, rye, barley, and any foods made with these grains. Under the ADAAA, celiac disease qualifies as a disability because it limits the major life activity of digestion. However, individuals with celiac disease each may present their disease differently, as some may experience gastrointestinal issues if they consume gluten, while for others it may cause skin rashes, migraines, or joint pain.

If a child requires a gluten-free diet, the sponsor must make the appropriate meal modifications. The sponsor can create a cycle menu that is gluten-free and meets the meal pattern to the best of their ability and rotate that menu each week for the student. Working with the household to see what foods the student typically eats is not required but recommended to create a menu that will work for both the sponsor and the household/student.

Many processed foods contain gluten unless they are labeled “gluten-free” or are made with corn, rice, soy, or other gluten-free grains. Foods that are likely to contain gluten include breads and bread products; pasta and couscous; grain-based desserts, such as cookies, cakes, and pies; breakfast cereals; crackers and snacks, such as pretzels, snack mix, pita chips, and croutons; seasoned snack foods; processed deli meats; soups and soup bases; and salad dressings and sauces, including soy sauce.

Diabetes and Carbohydrate Counting

Carbohydrates are naturally found in certain foods, such as grains, starchy vegetables, legumes, fruits and fruit juices, and dairy. Once consumed, these carbohydrates, also referred to as carbs, break down into glucose or sugar within the bloodstream. For those with diabetes, the process of getting the blood sugar into the body's cells for energy doesn't work properly. Therefore, carb counting is necessary for individuals with diabetes. Carb counting allows for the student (and healthcare individual(s) overseeing their care) to understand what kind of medical intervention may be necessary based on what they will be consuming, such as the amount of insulin needed with meals.

The sponsor is responsible for providing a carb count to the parent or guardian of a diabetic child for each food item served in one daily reimbursable meal choice. If the daily menu includes multiple meal choices, the sponsor is not required to provide carbohydrate counts for each meal possibility. For example, the sponsor can create a week’s worth of menus for students with diabetes with the carbohydrate counts and rotate that menu with the normal menu cycle. Working with the household to see what foods that the student typically eats is not required but recommended to create a menu that is plausible for the sponsor and household/student.

The sponsor is also responsible for providing information on the initial weights or measures of the planned food for the chosen meal. However, school food service personnel are not responsible for weighing or measuring leftover food after the child has consumed the meal, or determining the proper amount of carbohydrates needed or consumed. These tasks are the responsibility of the school nurse or other designated medical personnel, as established by parents and responsible staff.

The USDA specifies that school food service personnel can never diagnose health conditions, perform nutritional assessment, prescribe nutritional requirements, or interpret, revise, or change a diet order. If school food service personnel have questions about a child’s diet, prescribed meal substitutions, or any other required modifications, they should consult the appropriate medical personnel who work with the child, such as the school nurse or dietitian and the child’s recognized medical authority.

Conditions Requiring Different Portion Sizes or Caloric Amounts

Due to certain medical conditions or disabilities, a student may require a change in the portion size on their tray or change in the amount of calories provided with their meal. In order to make a change in calories or portion size, a medical statement form signed by a medical authority would be required. The recognized medical authority must specify any requirements for different portion sizes in the child’s medical statement and the reason why it is necessary. However, if the sponsor does not receive the a medical statement form, they cannot delay implementation of the accommodation.

Examples of this type of accommodation can include:

• an additional amount of a specific meal pattern component, such as a second serving of meat/meat alternates or grains;
• requiring a smaller amount of food than the minimum portion size required in the meal pattern, such as 1 ounce of meat/meat alternates instead of 2 ounces of meat/meat alternates for grades 9-12; or
• requiring that a child receives two of the same meal, e.g., two lunches. Note: While the sponsor must provide the two meals prescribed by the recognized medical authority, USDA regulations allow sponsors to only claim one lunch per child per day.

Tube Feedings

If a child has a disability that requires tube feedings, the child’s Section 504 plan and Individualized Health Care Plan will include feeding and swallowing as a component. For children who require tube feedings, USDA recommends using commercial nutritive formulas prescribed by a recognized medical authority and specially designed for tube feedings. School-made formula may not always have the correct consistency or nutritive content.

Proper administration of this type of feeding generally requires the skills of specially trained personnel, such as nurses or the specially trained aides who regularly work with the child. Sponsors should be aware of the potential liability if someone without sufficient training and direction is performing a task or activity, such as developing or modifying a diet order prescribed by a recognized medical authority or administering tube feedings.

If the child has an IEP, special education funds may cover the cost of commercial formulas and special personnel. If the child does not have an IEP, these costs may, as appropriate, be charged in part to the sponsor or assigned to the school district’s general fund or other funding sources.

With appropriate documentation on the medical statement, the sponsor could be responsible on a case-by-case basis for the cost of tube feeding formulas that are required as substitutions. However, school food service personnel are not responsible for physically feeding the child.

Phenylketonuria (PKU)

Phenylketonuria (PKU) is a rare genetic disorder characterized by the inability of the body to metabolize the essential amino acid, phenylalanine (Phe). Amino acids, usually obtained from the food we eat, are the building blocks for our body’s proteins. In children with PKU, the enzyme that breaks down this amino acid is missing causing excessive levels of phenylalanine in the blood and body tissues. Excess phenylalanine is toxic to the central nervous system and causes severe neurological complications, including IQ loss, memory loss, concentration problems, and in some cases, severe mental retardation.

Phenylalanine is found in all foods that contain protein. Therefore, children with PKU need to restrict their intake of protein. The amount of drink and food a child with PKU has daily is carefully calculated by the medical staff and family. Often times, they receive a specifically formulated drink containing the nutrients that are lost due to a limiting diet. Also, they need to avoid aspartame, an artificial sweetener (i.e. NutraSweet or Equal) containing phenylalanine. It is extremely important not to allow any food that is forbidden. Even a little taste can result in an increase in Phe levels in the blood. Supervision of younger children with PKU may be needed to prevent sharing or “tastes.” Many school districts will put together a special health care, 504 plan or IEP to ensure that the child’s PKU is safely and consistently managed at school.

Texture Modifications

Students with certain medical conditions and disabilities may require a texture modification of items served to them. This could be due to a variety of conditions, such as to prevent choking and aspiration, muscle weakness or paralysis in the mouth or digestive system, or sensory processing concerns. Texture modifications can include changing the consistency of liquids. For instance, sponsors might be directed to modify to a honey or pudding-thick consistency or have a liquid thinned. Other directions might include having items pureed, diced, chopped, etc. to make the items easier to chew and digest. Medical statements are not required when texture modifications are made to food items on the menu. Sponsors may apply stricter guidelines and require a medical statement on file concerning the requested texture modifications. This serves as a precaution to ensure safe and appropriate meals for the child, protect the sponsor, and minimize misunderstandings; however the sponsor cannot delay the accommodation until the medical statement form is obtained.

Unless otherwise specified by the recognized medical authority, only menu items in their appropriate portion sizes should be modified for texture. This is because these meals still must meet the meal patterns and dietary specifications and are included in the nutrient analysis of meals. If the requested items do not meet the meal pattern for any reason, you must then have a signed medical statement form.

As with other dietary substitutions, no additional USDA reimbursement is available for texture-modified meals. If a child must have a pureed meal, it is reasonable to expect school food service to purchase a blender or food processor and to have the meal prepared by food service personnel.

Temporary Disabilities

The requirements for providing meal modifications for children with disabilities apply regardless of the duration of the disability. If a disability is episodic and substantially limits a major life activity, sponsors must provide a reasonable modification based on the child’s medical statement signed by a state licensed healthcare professional with prescriptive authority or registered dietitian. Whether a temporary impairment is a disability, must be determined on a case-by-case basis, taking into consideration both the duration (or expected duration) of the impairment and the extent to which it limits a major life activity of the affected individual.

An example of a temporary disability, is a child who had major oral surgery due to an accident and is unable to consume food for a significant period of time unless the texture is modified. The sponsor must make the meal modification, even though the child is not “permanently” disabled. Illness or injury, such as a cold, the flu, or a minor broken bone, are generally not considered conditions that require meal modifications.

Mental Impairment

Under Section 504, qualified individuals with disabilities are defined as persons with a physical or mental impairment which substantially limits one or more major life activities. This means that a student with a mental impairment could request a meal modification related to their disability. A mental impairment is a mental or psychological disorder and includes mental retardation, emotional or mental illness, and specific learning disorders. Sometimes these accommodations can be written into or will be included within an IEP or 504 Plan for the student. If the accommodation requires that they do not have a complete reimbursable meal, make sure that either a medical statement form signed by a medical authority is on file or the IEP that includes details is signed by a medical authority. The IEP can act in place of a more traditional medical statement form as long as all necessary and required information is included.

For students with a mental impairment, consider their ability to verbally or non-verbally communicate needs and symptoms if they happen to occur. Accommodations could include a different meal schedule, not having certain food items on the tray for the student, removing items with certain allergens, changing the size or shape of foods, having extra time for eating, or the use of certain utensils or trays. The sponsor should maintain open communication with school staff and the student's family to ensure that everyone has agreed on the best methods for accommodating this child.

Thank you!

Thank you for diligently working to provide meals that are safe and healthy for students with special dietary needs! Your hard work is appreciated. If you have any questions regarding special dietary needs, please never hesitate to reach out to IDOE.

Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

mail:

U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW Washington, D.C. 20250-9410; or

fax: (833) 256-1665 or (202) 690-7442; or

email: Program.Intake@usda.gov

This institution is an equal opportunity provider.