+-----------+----------------------------------------------------------+
| **United  | **Accommodating Children with**                          |
| States**  |                                                          |
|           |                                                          |
| **D       |                                                          |
| epartment |                                                          |
| of**      |                                                          |
|           |                                                          |
| **Agri    |                                                          |
| culture** |                                                          |
+-----------+----------------------------------------------------------+
| **Food    | **Special Dietary Needs in the**                         |
| and**     |                                                          |
|           |                                                          |
| **Nu      |                                                          |
| trition** |                                                          |
|           |                                                          |
| **        |                                                          |
| Service** |                                                          |
+-----------+----------------------------------------------------------+
|           | **School Nutrition Programs**                            |
+-----------+----------------------------------------------------------+
|           |                                                          |
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|           |                                                          |
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|           |                                                          |
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|           |                                                          |
+-----------+----------------------------------------------------------+
|           | **Guidance for School Food Service Staff**               |
+-----------+----------------------------------------------------------+

![](media/image1.png){width="1.2777777777777777in"
height="0.9534722222222223in"}

+-----------------------------------------------------------------------+
| In accordance with Federal law and 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 Civil Rights, Room 326-W, Whitten Building, 1400 Independence      |
| Avenue, SW, Washington, D.C., 20250-9410, or call 202-720-5964 (voice |
| and TDD). USDA is an equal opportunity provider and employer.         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

No substantive changes were made to this manual. Minor updates were made
and several obsolete appendices were deleted.

Fall 2001

######## GUIDANCE FOR ACCOMMODATING CHILDREN

**WITH SPECIAL DIETARY NEEDS**

**IN THE SCHOOL NUTRITION PROGRAMS**

**TABLE OF CONTENTS**

I. INTRODUCTION

II\. DEFINITIONS OF DISABILITY AND OF OTHER

SPECIAL DIETARY NEEDS

A.
Disability......................................................\..........3

B. Other Special Dietary
Needs.................................\......\...6

III\. SCHOOL ISSUES

## A. School Food Service Responsibilities..............................7

B. Funding
Sources.....................................................10

C. Helpful
Resources................................................\...14

D. Information
Sources..............................................\...16

IV. LEGAL CONCERNS AND LIABILITY IN WORKING

WITH CHILDREN WITH DISABILITIES

> A. School Responsibility To Make

Accommodations...................................................18

> B. Personal Responsibility In Cases Of

#########  Negligence..........................................................20

V. SITUATIONS AND RESPONSES

##  A. Meals and/or Foods Outside of the Normal

Meal Service........................................................23

B. Special Needs Which May or May Not Involve

> Disabilities......................................................\.....25

C. Responsibilities of Food Service Management

Companies (FSMC) and Other Food

> Service Operations.................................................27
>
> SITUATIONS AND RESPONSES (continued)
>
> D. Feeding in Separate Facilities -- Generally

Not Acceptable...................................................\...28

> E. Temporary
> Disabilities..............................................29

F. Complicated Feedings...............................................29

G. School Food Service Account.....................................31

H.
Documentation.......................................................32

VI\. SAMPLE DOCUMENTATION FOR SPECIAL

> DIETARY NEEDS

A. FIG 1. Eating/Feeding Evaluation.................................34

B. FIG 2. Information Card............................................35

VII\.
GLOSSARY..............................................................36

**LIST OF APPENDICES**

*APPENDIX A*

**FNS Instruction 783-2, Revision 2, Meal Substitutions for Medical or
Other Special Dietary
Reasons**.............................................41

U.S. Department of Agriculture Nondiscrimination

## Exhibit A - Regulations: 7 CFR Part 15b\...\...\...\...\...\...\...\...\...\...\...\............47

*APPENDIX B*

**USDA, Food and Nutrition Service**

Regional Contacts Special Nutrition
Programs\...\...\...\...\...\...\...\...\............48

Regional Contacts Civil
Rights...............................................49

*APPENDIX C*

**Department of Health and Human Services**

Regional
Contacts\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................\...\....50

*APPENDIX D*

**Voluntary and Professional**

**Health
Organizations**\...\...\...\...\...\...\...\...\...\...\...\...\...\...\............................53

**GUIDANCE FOR ACCOMMODATING CHILDREN**

**WITH SPECIAL DIETARY NEEDS**

**IN THE SCHOOL NUTRITION PROGRAMS**

# I. INTRODUCTION

In recent years, we have seen increasing emphasis on the importance of
ensuring that children with disabilities have the same opportunities as
other children to receive an education and education-related benefits,
such as school meals.

Congress first addressed this concern in *The Rehabilitation Act of
1973*, which prohibits discrimination against qualified persons with
disabilities in the programs or activities of any agency of the federal
government\'s executive branch or any organization receiving federal
financial assistance.

Subsequently, Congress passed the *Education of the Handicapped Act,*
(now, the *Individuals with Disabilities Education Act*), which requires
that a free and appropriate public education be provided for children
with disabilities, who are aged 3 through 21, and the *Americans with
Disabilities Act*, a comprehensive law which broadens and extends civil
rights protections for Americans with disabilities.

One effect of these laws has been an increase in the number of children
with disabilities who are being educated in regular school programs. In
some cases, the disability may prevent the child from eating meals
prepared for the general school population.

The U.S. Department of Agriculture\'s (USDA) nondiscrimination
regulation (7 CFR 15b), as well as the regulations governing the
National School Lunch Program and School Breakfast Program, make it
clear that substitutions to the regular meal must be made for children
who are unable to eat school meals because of their disabilities, when
that need is certified by a licensed physician.

1

In most cases, children with disabilities can be accommodated with
little extra expense or involvement. The nature of the child\'s
disability, the reason the disability prevents the child from eating the
regular school meal, and the specific substitutions needed must be
specified in a statement signed by a licensed physician. Often, the
substitutions can be made relatively easily. There are situations,
however, which may require additional equipment or specific technical
training and expertise. When these instances occur, it is important that
school food service managers and parent(s) be involved at the outset in
preparations for the child\'s entrance into the school.

This guidance describes some of the factors which must be considered in
the early phases of planning and suggests ways in which the school food
service can interact with other responsible parties in the school and
the community at large to serve children with disabilities.

The guidance is based on the policy guidelines outlined in the FNS
Instruction 783-2, Revision 2, *Meal Substitutions for Medical or Other
Special Dietary Reasons.*

Serving children with disabilities presents school food service staff
with new challenges as well as rewards. This guidance presents
information on how to handle situations that may arise and offers advice
about such issues as funding and liability.

The guidance was prepared in consultation with the U.S. Department of
Justice and the U.S. Department of Education and will be periodically
updated to reflect new scientific information or new statutory and
program guidelines.

2

**II. DEFINITIONS OF DISABILITY AND OF OTHER**

**SPECIAL DIETARY NEEDS**

**A. DISABILITY**

***Rehabilitation Act of 1973* and the *Americans with ***

***Disabilities Act***

Under Section 504 of the *Rehabilitation Act of 1973,* and the
*Americans with Disabilities Act* (ADA) of 1990, a \"person with a
disability\" means any person who has a physical or mental impairment
which substantially limits one or more major life activities, has a
record of such an impairment, or is regarded as having such an
impairment.

The term \"physical or mental impairment\" includes many diseases and
conditions, a few of which may be:

-   orthopedic, visual, speech, and hearing impairments;

-   cerebral palsy;

-   epilepsy;

-   muscular dystrophy;

-   multiple sclerosis;

-   cancer;

-   heart disease;

-   metabolic diseases, such as diabetes or phenylketonuria (PKU);

-   food anaphylaxis (severe food allergy);

-   mental retardation;

-   emotional illness;

-   drug addiction and alcoholism;

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-   specific learning disabilities;

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-   HIV disease; and

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-   tuberculosis.

    Please refer to the Acts noted above for a more detailed
    explanation.

    Major life activities covered by this definition include caring for
    one\'s self, eating, performing manual tasks, walking, seeing,
    hearing, speaking, breathing, learning, and working.

    3

# Individuals with Disabilities Education Act {#individuals-with-disabilities-education-act .unnumbered}

The term child with a \"disability\" under Part B of the *Individuals
with Disabilities Education Act* (IDEA) means a child evaluated in
accordance with IDEA as having one or more of the recognized thirteen
disability categories and who, by reason thereof, needs special
education and related services.

IDEA recognizes thirteen disability categories which establish a
child\'s need for special education and related services. These
disabilities include:

-   autism;

-   deaf-blindness;

-   deafness or other hearing impairments;

-   mental retardation;

-   orthopedic impairments;

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-   other health impairments due to chronic or acute health problems,
    such as asthma, diabetes, nephritis, sickle cell anemia, a heart
    condition, epilepsy, rheumatic fever, hemophilia, leukemia, lead
    poisoning, tuberculosis;

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-   emotional disturbance;

-   specific learning disabilities;

-   speech or language impairment;

-   traumatic brain injury; and

-   visual impairment; including blindness which adversely affects a
    child's educational performance, and

-   multiple disabilities.

    Attention deficit disorder or attention deficit hyperactivity
    disorder may fall under one of the thirteen categories.
    Classification depends upon the particular characteristics
    associated with the disorder and how the condition manifests itself
    in the student, which will determine the category.

    The Individualized Education Program or IEP means a written
    statement for a child with a disability that is developed, reviewed,
    and revised in accordance with the IDEA and its implementing
    regulations. The IEP is the cornerstone of the student's educational
    program that contains the program of special education and related
    services to be provided to a child with a disability covered under
    the IDEA.

    4

    **NOTE:** Some states supplement the IEP with a written statement
    specifically designed to address a student's nutritional needs.
    Other states employ a "Health Care Plan" to address the nutritional
    needs of their students. For ease of reference, the term "IEP" is
    used to reflect the IEP as well as any written statement designating
    the required nutrition services.

    When nutrition services are required under a child\'s IEP, school
    officials need to make sure that school food service staff are
    involved early on in decisions regarding special meals.

# Physician\'s Statement for Children with Disabilities {#physicians-statement-for-children-with-disabilities .unnumbered}

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:

 the child\'s disability;

 an explanation of why the disability restricts the child\'s diet;

 the major life activity affected by the disability;

-   the food or foods to be omitted from the child\'s diet, and the food
    or choice of foods that must be substituted.

# In Cases of Food Allergy {#in-cases-of-food-allergy .unnumbered}

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.

5

**B. OTHER SPECIAL DIETARY NEEDS**

The school food service may make food substitutions, at their
discretion, for individual children who do not have a disability, but
who are medically certified as having a special medical or dietary need.

Such determinations are only made on a case-by-case basis. This
provision covers those children who have food intolerances or allergies
but do not have life-threatening reactions (anaphylactic reactions) when
exposed to the food(s) to which they have problems.

**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:

 an identification of the medical or other special dietary condition
which restricts the child\'s diet;

 the food or foods to be omitted from the child\'s diet; and

 the food or choice of foods to be substituted.

6

**III. SCHOOL ISSUES**

The school food service, like the other programs in the school, is
responsible for ensuring that its benefits (meals) are made available to
all children, including children with disabilities. This raises
questions in a number of areas:

A. What are the responsibilities of the school food service?

B. Where can additional funds be obtained?

C. Who can provide more information and technical assistance?

**A. SCHOOL FOOD SERVICE RESPONSIBILITIES**

-   School food service staff must make food substitutions or
    modifications for students with disabilities.

-   Substitutions or modifications for children with disabilities must
    be based on a prescription written by a licensed physician.

-   The school food service is encouraged, but not required, to provide
    food substitutions or modifications for children without
    disabilities with medically certified special dietary needs who are
    unable to eat regular meals as prepared.

-   Substitutions for children without disabilities, with medically
    certified special dietary needs must be based on a statement by a
    recognized medical authority.

-   Under no circumstances are school food service staff to revise or
    change a diet prescription or medical order.

-   For USDA's basic guidelines on meal substitutions and accessibility,
    see FNS Instruction 783-2, Revision 2, *Meal Substitutions for
    Medical or Other Special Dietary Reasons*, in **Appendix A**.

7

-   It is important that all recommendations for accommodations or
    changes to existing diet orders be documented in writing to protect
    the school and minimize misunderstandings. Schools should retain
    copies of special, non-meal pattern diets on file for reviews.

-   The diet orders do not need to be renewed on a yearly basis; however
    schools are encouraged to ensure that the diet orders reflect the
    current dietary needs of the child.

    **Providing Special Meals to Children with Disabilities**

    The school food service is required to offer special meals, at no
    additional cost, to children whose disability restricts their diet
    as defined in USDA\'s nondiscrimination regulations, 7 CFR Part 15b.

 If a child\'s IEP includes a nutrition component, the school should
ensure that school food service managers are involved early on in
decisions regarding special meals or modifications.

 The school food service is not required to provide meal services to
children with disabilities when the meal service is not normally
available to the general student body, unless a meal service is required
under the child\'s IEP.

For example, if a school breakfast program is not offered, the school
food service is not required to provide breakfast to the child with a
disability, unless this is specified in the child\'s IEP.

However, if a student is receiving special education and has an IEP, and
the IEP indicates that the child needs to be served breakfast at school,
then the school is required to provide this meal to the child and may
choose to have the school food service handle the responsibility. This
is discussed in more detail in *Section V*, under Situation 2.

**Menu Modifications for Children with Disabilities**

Children with disabilities who require changes to the basic meal (such
as special supplements or substitutions) are required to provide
documentation with accompanying instructions from a licensed physician.

8

This is required to ensure that the modified meal is reimbursable, and
to ensure that any meal modifications meet nutrition standards which are
medically appropriate for the child.

**Texture Modifications for Children with Disabilities**

For children with disabilities who only require modifications in texture
(such as chopped, ground or pureed foods), a licensed physician\'s
written instructions indicating the appropriate food texture is
recommended, but not required.

However, the State agency or school food authority may apply stricter
guidelines, and require that the school keep on file a licensed
physician\'s statement concerning needed modifications in food texture.

 In order to minimize the chance of misunderstandings, it is
recommended that the school food service, at a minimum, maintain written
instructions or guidance from a licensed physician regarding the texture
modifications to be made. For children receiving special education, the
texture modification should be included in the IEP.

 School food service staff must follow the instructions that have been
prescribed by the licensed physician.

**Serving the Special Dietary Needs of Children Without**

**Disabilities**

Children without disabilities, but with special dietary needs requiring
food substitutions or modifications, may request that the school food
service meet their special nutrition needs.

 The school food authority will decide these situations on a
case-by-case basis. Documentation with accompanying information must be
provided by a recognized medical authority.

 While school food authorities are encouraged to consult with
recognized medical authorities, where appropriate, schools are not
required to make modifications to meals based on food choices of a
family or child regarding a healthful diet.

9

**B. FUNDING SOURCES**

# Price of Meals

Meals must be served free or at a reduced price (a maximum of 40 cents
for lunch and 30 cents for breakfast) to children who qualify for these
benefits regardless of whether or not they have a disability.

Schools may not charge children with disabilities or with certified
special dietary needs who require food substitutions or modifications
more than they charge other children for program meals or snacks.

**Incurring Additional Expenses**

In most cases, children with disabilities can be accommodated with
little extra expense or involvement. If additional expenses are incurred
in providing food substitutions or modifications for children with
special needs, generally the school food authority should be able to
absorb the cost of making meal modifications or paying for the services
of a registered dietician.

However, when the school food service has difficulty covering the
additional cost, there are several alternative sources of funding which
school food service managers, school administrators, parents or
guardians, and teachers may consider. These sources include the school
district\'s general fund and the additional funding sources listed
below.

Any additional funding received by school food services for costs
incurred in providing special meals must accrue to the nonprofit school
food service account.

10

**POTENTIAL FUNDING SOURCES**

**Individuals with Disabilities Education Act**

The *Individuals with Disabilities Education Act* (IDEA), through the
Part B Program, provides Federal funds to assist States and school
districts in making a **\"free appropriate public education\"**
available to eligible children with specified disabilities residing
within the State.

Students with specified physical, mental, emotional or sensory
impairments that need special education and related services are
eligible for services under IDEA, **at no cost to parents.**

In appropriate situations, nutrition services may be specified as
**special education** (specially designed instruction) or a **related
service** (support services required to assist a child with a disability
to benefit from special education).

Services which may be funded through IDEA include: (1) purchase of
special foods, supplements, or feeding equipment; (2) consultation
services of a registered dietitian or nutrition professional; and

\(3\) assistance of a special education teacher, occupational therapist
or other health professional in feeding the child or developing feeding
skills.

**Website address: Department of Education/IDEA: http://www.ed.gov,
(**scroll down to "Most Requested Items" Disabilities Education (IDEA))

# Medicaid

Title XIX of the *Social Security Act* is an entitlement program which
finances medical services for certain individuals and families with low
income and resources.

Within broad Federal guidelines, a State or territory:

(1) establishes its own eligibility standards; (2) determines the type,
    amount, duration, and scope of services; (3) sets the rates of
    payment for services; and (4) administers its own program.

11

The Medicaid program, jointly funded by Federal and State governments,
varies considerably from State to State as each State adapts the program
to its own unique environment.

In the case of certain low-income children eligible for Medicaid,
Medicaid may pay for services that are medical and remedial in nature.
These services may include special dietary supplements, eating devices,
and nutritional consultation as medically necessary.

Medicaid reimbursement is paid directly to the provider of services,
such as a physician, pharmacy, medical equipment supplier, clinic, and,
in certain situations, the school food authority and/or school.
Questions regarding provider qualifications should be directed to your
State Medicaid agency.

If you have questions about who has access to Medicaid, how to qualify
as an authorized provider, or what services are covered by Medicaid in
your State, contact your State Medicaid agency.

For information or a referral, check with the Medicaid division, at the
regional office of the Health Care Financing Administration for your
State. (See **Appendix C)**

**Website address: http://www.hcfa.gov/medicaid/.**

**Early and Periodic Screening, Diagnostic and Treatment**

**Program**

Medicaid\'s child health program, the Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) Program is a preventive and
comprehensive health care benefit for Medicaid-eligible individuals up
to age 21. EPSDT includes screening for dental, hearing and vision
services. An objective of the EPSDT Program is to detect and treat
health problems and conditions early before they become more complex and
costly. The EPSDT Program allows providers, including schools, to be
reimbursed for preventive and treatment services for Medicaid-eligible
children. Questions regarding EPSDT coverage under Medicaid should be
directed to the State Medicaid agency or to your State EPSDT
Coordinator.

**Website address: http://www.hcfa.gov/medicaid/EPSDThm.htm**

12

**Supplemental Security Income**

Supplemental Security Income (SSI), under Title V of the *Social
Security Act*, provides rehabilitative services to children under age 16
who are receiving benefits under SSI, to the extent that Medicaid does
not cover the service. SSI provides basic income for needy children
under age 18 (students under age 22) who are blind or who have a severe
disability or chronic illness.

For information on SSI eligibility, contact your local Social Security
Office or call the Social Security Administration's toll free telephone
number, 1-800-772-1213, (TTY/TDD, 1-800-325-0778).

**Website address: http://www.SSA.gov, and scroll down to Supplemental
Security Income**

**Medicare**

Medicare provides services for children and adults with end-stage renal
(kidney) disease. However, Medicare coverage of nutritional supplies is
generally limited to durable medical equipment such as a feeding pump or
other special (parenteral or enteral) nutritional feeding equipment
necessary for people who cannot be sustained through normal means of
feeding by mouth.

For more information, telephone the toll free Medicare Hotline at,
1-800-633-4227 or (TTY/TDD, 1-800-820-1202).

## **Website address: http://www.medicare.gov**

**Maternal and Child Health (MCH) Services Block Grants**

The Maternal and Child Health Bureau, at the Department of Health and
Human Services, administers Maternal and Child Health Services Block
Grants, authorized under Title V of the *Social Security Act*. These
grants enable States to assess health needs and provide a wide range of
community-based services for children with special health care needs.

13

State Title V programs work closely with community health centers,
public health clinics, and school health programs. Contact the Regional
MCH Program Consultant for your State, listed in **Appendix C**, for
information about your State's Title V program activities.

**Community Sources**

Parent Teacher Associations (PTA), voluntary health associations, local
civic organizations, and other community-based groups may be able to
assist with the procurement of equipment and provide other support
services. See **Appendix D** for a partial list of voluntary and
professional health organizations which offer information and support
for various disabilities or special health care needs.

**C. HELPFUL RESOURCES**

School food service staff should work closely with the support people
who are familiar with the needs of the child. The child\'s parents or
guardians, teachers, occupational and physical therapists, special
education staff, and the school nurse are valuable resources.

**Local health department, hospital, or medical center registered
dietitians** may be able to provide assistance in understanding diet
orders, developing and modifying meal plans and menus, special food item
purchases, and other aspects of feeding children with special needs.

In addition, the following resources may provide technical assistance or
referrals to qualified nutrition and health professionals:

-   **State Title V Directors, Maternal and Child Health (MCH)**

Each State has a Title V director responsible for overseeing State
programs for children with special health care needs. Most States also
have public health nutritionists who are responsible for nutritional
services for these children.

# Contact the Regional MCH Program Consultant for your State listed in Appendix C for information on State Title V program activities or refer to your State Title V MCH personnel.

# 

14

-   **Registered Dietitians of the American Dietetic**

**Association (ADA)**

Registered Dietitians (R.D.) can answer questions on special diets and
menu planning to help school food service staff better understand a
child's special dietary needs. An R.D. may work with the recognized
medical authority and the school food service to help meet a child's
special nutritional needs and ensure that menus comply with the diet
order. These types of services are allowable program costs.

The ADA\'s toll free Consumer Nutrition Information/Hotline is

1-800-366-1655 which can provide referrals to qualified R.D.s in your
area as well as daily nutrition messages.

**Website address: http://www.eatright.org**

-   **University Affiliated Programs for Developmentally**

**Disabled (UAP)**

UAPs were established to support the independence, productivity, and
community integration of all citizens with developmental disabilities.

Within their States, UAPs serve as links between the academic world and
the delivery of services to persons with developmental disabilities.
UAPS also provide families and individuals with a variety of support
services.

## 

## For a referral to a UAP in your area, contact the National Office of the American Association of University Affiliated Programs at (301) 588-8252.

## **Website address: http://www.aauap.org**

-   **Regional Disability and Business Technical Assistance**
    **Centers**

Ten regional centers are funded by the National Institute on Disability
Rehabilitation and Research of the U.S. Department of Education to
provide information and technical assistance on the Americans with
Disabilities Act (ADA). The Regional ADA Coalition in your area may also
be helpful.

15

Copies of ADA documents, supplied by the Equal Employment Opportunity
Commission and the Department of Justice, may be obtained at any of the
regional centers. These materials are available in standard print, large
print, Braille, on audiocassette and computer disk.

For the telephone number and address of your regional center, call the
ADA Technical Assistance Center's toll free number:

1-800-949-4ADA.

-   **Other Health Care and Disability Related Organizations**

**Appendix D** contains a listing of organizations which may offer
assistance regarding children with different health care needs. The
appendix includes such organizations as the American Diabetes
Association, the Food Allergy and Anaphylaxis Network, United Cerebral
Palsy

Association, the Easter Seal Society, and many more.

**D. INFORMATION SOURCES**

There are a growing number of excellent information services that can
provide resources and answer your questions about accommodating children
with special dietary needs.

The following are federally funded sources:

-   **Food and Nutrition Information Center** (FNIC).

    FNIC is an information center located at USDA's National
    Agricultural Library (NAL). FNIC staff has prepared resource lists
    on food service topics that are located on their website. Phone FNIC
    for more information. (301) 504-5719, or TTY: (301) 504-6856).

    []{.mark}

    Website address: http://www.nal.usda.gov/fnic.

    FNIC's [Healthy School Meals Resource System]{.underline} offers
    online training materials and connects with other food service
    resources.

###### Website address: http://schoolmeals.nal.usda.gov

16

-   National Agriculture Library (NAL)

    NAL has a large collection of books, videos, teaching kits,
    professional journals and other library resources on food and
    nutrition topics. Phone NAL for more information. (301) 504-5755.

    []{.mark}

    Website address: http://www.nal.usda.gov

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-   **National Food Service Management Institute (NFSMI), University of
    Mississippi**

    NFSMI at the University of Mississippi is a national resource for
    the child nutrition programs. It provides information services and
    referral in all areas of nutrition and school food service. NFSMI
    staff can give practical answers to question regarding serving
    children with special nutritional needs. Call the Help Desk at
    1-800-321-3054, or (662) 915-7658.

    Website address: http://www.nfsmi.org.

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-   **National Information Center for Children and Youth with
    Disabilities (NICHCY)**

    NICHCY is an information and referral center for children with
    disabilities and disability related issues which receives funding
    through the U.S. Department of Education. Information specialists
    provide information in English and Spanish regarding services about
    specific disabilities, special education and related services,
    education programs, family issues or disability organizations. The
    toll free number is 1-800-695-0285.

    NICHCY staff has prepared State Resource Sheets for each State which
    can be downloaded from its web site. The resource sheet for your
    State will help you locate government agencies, chapters of
    disability organizations, parent training and information projects.
    The resource sheet can also refer you to local sources of
    information and assistance.

# Website address: http://www.nichcy.org {#website-address-httpwww.nichcy.org .unnumbered}

17

IV\. LEGAL CONCERNS AND LIABILITY IN WORKING WITH CHILDREN WITH
DISABILITES

A growing body of Federal law clearly intends that children with
disabilities have the same rights and privileges, and the same access to
benefits, such as school meals, as children without disabilities.
Consequently, schools which do not make appropriate program
accommodations for children with disabilities, could be found in
violation of Federal civil rights laws.

School administrators and food service staff should be aware of two
issues involving liability: (1) the school\'s responsibility for
providing program accommodations for children with disabilities and (2)
the question of personal responsibility in cases of negligence. These
two issues are discussed below.

A. SCHOOL RESPONSIBILITY TO MAKE ACCOMMODATIONS

**Section 504**

**Rehabilitation Act of 1973**

Section 504 of the *Rehabilitation Act of 1973* specifically

mandates that:

\"no otherwise qualified individual with a disability

shall solely by reason of his or her disability be

excluded from the participation in, be denied the

benefits of, or be subjected to discrimination under

any program or activity receiving Federal

financial assistance.\"

This mandate is incorporated in 7 CFR Part 15b, USDA's nondiscrimination
regulations.

***Individuals with Disabilities Education Act***

Part B of the *Individuals with Disabilities Education Act (IDEA)*
assists States and school districts in making a **\"free appropriate
public education\"** available to eligible students.

18

Under IDEA, a \"free appropriate public education\" means special
education and related services provided under public supervision and
direction in conformity with an individualized education

program (IEP) at no cost to parents.

In appropriate situations, nutrition services could be considered
"special education\" (specially designed instruction) or a "related
service\", (support services required to assist a child with a
disability to benefit from special education).

**Title II**

# Americans With Disabilities Act {#americans-with-disabilities-act .unnumbered}

Title II of the *Americans with Disabilities Act* (ADA), enacted in
1990, requires equal availability and accessibility in State and local
government programs and services, including public schools.

In this respect, the ADA underscores the statutory prohibition of
Section 504 of the Rehabilitation Act of 1973, against discrimination on
the basis of disability by programs receiving Federal funding, such as
reimbursement under the school meal programs.

Title II of the ADA does not impose any major new requirements on school
districts because the requirements of Title II and Section 504 are
similar. Virtually all school districts receive Federal financial
assistance and have been required to comply with Section 504 for many
years.

# Title III {#title-iii .unnumbered}

# Americans With Disabilities Act {#americans-with-disabilities-act-1 .unnumbered}

Title III of the ADA extends requirements for public accommodations to
privately owned facilities.

All private schools participating in the federally funded child
nutrition programs must make accommodations to enable children with
disabilities to receive school meals.

## Although religious organizations are exempt from the public accommodations requirements of Title III, church-operated schools which receive Federal funding assistance under the child nutrition programs continue to be subject to the non-discrimination requirements of Section 504. {#although-religious-organizations-are-exempt-from-the-public-accommodations-requirements-of-title-iii-church-operated-schools-which-receive-federal-funding-assistance-under-the-child-nutrition-programs-continue-to-be-subject-to-the-non-discrimination-requirements-of-section-504. .unnumbered}

19

**B. PERSONAL RESPONSIBILITY IN CASES OF NEGLIGENCE**

In order to accommodate a child with a disability, the school must
ensure that both facilities and personnel are adequate to provide
necessary services.

In some cases, it may be advisable for specially trained personnel, such
as a registered dietitian to provide guidance to the school food service
staff on how to modify a child's meals to comply with requirements as
provided in the licensed physician's statement.

Moreover, for certain children with disabilities, it may be necessary to
have a nurse or trained health aide feed the child or have a specially
trained professional, such as a special education teacher, occupational
therapist, or speech therapist, assist the child to develop and improve
his or her eating skills.

**Administering Feedings**

For children requiring assistance in eating, the determination of who
will feed the child is a local school decision.

While the school food service is specifically responsible for providing
the necessary foods needed by a child with a disability, it is not the
specific responsibility of the school food service staff to physically
feed the child.

Furthermore, schools should be aware that they could be held liable if
persons without sufficient training are performing tasks or activities
such as developing or modifying a diet order prescribed by a licensed
physician or administering tube feedings.

**Diet Orders**

If school food service staff have questions about the diet order, the
prescribed meal substitutions, or any other modifications that are
required, the child\'s physician and/or a registered dietitian should be
consulted. If the school food service director cannot obtain local level
assistance, the State agency should be consulted for technical
assistance.

20

Under no circumstances should school food service staff diagnose health
conditions, perform a nutritional assessment, prescribe nutritional
requirements, or **interpret**, **revise** or **change** a diet order.

# Negligence {#negligence .unnumbered}

If a mishap should occur, personal liability would normally depend on
whether or not the person responsible for the feeding has been
negligent.

In these cases, a determination that a person acted negligently would be
made on the basis of State laws and the facts in the individual
situation.

In general, negligence occurs when a person fails to exercise the care
expected of a prudent person.

Persons involved with special feeding operations should, therefore, make
sure that they thoroughly understand the required procedures and
techniques and are careful to follow instructions.

For specific guidance concerning personal liability, the school
officials should contact State or local legal counsel.

21

# V. SITUATIONS AND RESPONSES {#v.-situations-and-responses .unnumbered}

In order to provide some practical guidelines, this section discusses
several situations which are relatively common and which have raised
questions in the past. These examples have been included because they
illustrate certain principles and give general direction on what schools
and institutions must do under the law. In all situations where a
student's IEP indicates nutritional requirements or components, schools
must make these accommodations.

Remember that circumstances vary from case to case. Schools should not
automatically assume that the responses given in this section would
always apply. When an actual situation occurs which has elements
different from those discussed here, the State agency should be
consulted for guidance.

The examples in this section have been grouped under the following
topics:

-   Meals and/or foods outside of the normal

    meal service

-   Special needs which may or may not involve

    disabilities

-   Responsibilities of food service management

    companies and other food service operations

```{=html}
<!-- -->
```
-   Feeding in separate facilities---generally not acceptable

```{=html}
<!-- -->
```
-   Temporary disabilities

-   Complicated feedings

-   School food service account and

-   Documentation

22

A. MEALS AND/OR FOODS OUTSIDE OF THE NORMAL MEAL SERVICE

Situation 1:

As part of the therapy for a child with a disability, the licensed
physician has required the child to consume six cans of cranberry juice
a day. The juice is to be served at regular intervals, and some of these
servings would occur outside of the normal school meal periods. Is the
school food service required to provide all of the servings of juice?

**Response:**

No. 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.

In this example, the school food service would be required to provide
(and pay for) cranberry juice as part of the regular reimbursable
breakfast, lunch and/or snack service. However, the school food service
would not be required to pay for other servings throughout the school
day [unless]{.underline} specified in the Individualized Education Plan
(IEP).

It must be recognized that there will be exceptions to this general
rule. For example, residential child care institutions (RCCI), such

as juvenile correction facilities, may be required to provide additional
foods or servings since the child would have no other recourse for
meals.

It must be stressed that such accommodation would depend on the specific
circumstances of each case and, in any event, would go beyond
obligations under the school nutrition programs.

In general, additional servings beyond what is required under the
program meal may, but need not, be charged to the nonprofit food service
account.

23

**Situation 2:**

A child with a disability must have a full breakfast each morning. Is
the school food service required to provide a breakfast for this child
even though a breakfast program is not available for the general school
population?

**Response:**

As noted above, the school food service is not required to provide
services and meals to children with disabilities that are not otherwise
available to children who are not disabled. If the school does not have
a breakfast program already, it does not need to initiate a program
exclusively for children with disabilities.

## However, if the IEP requires that a child receive a breakfast at school, the school must provide the service, and may choose to have the school food service handle the responsibility.

Another exception to the general rule concerns a child with a disability
who resides in a RCCI and requires special food service. In the case of
RCCIs, the institution serves as the child\'s home, and the child would
have no other recourse for meals. The RCCI must provide the child a full
breakfast, if this is specified in the licensed physician\'s statement
or in the IEP.

**Situation 3:**

A licensed physician has prescribed portion sizes that exceed the
minimum quantity requirements set forth in the regulations. Is the
school required to provide these additional quantities?

**Response:**

Yes. The school must provide the child food portions which exceed the
minimum quantity requirements, if specifically prescribed in the
licensed physician\'s statement.

24

B. SPECIAL NEEDS WHICH MAY OR MAY NOT INVOLVE DISABILITIES

**Situation 4:**

A child has a life threatening allergy which causes an anaphylactic
reaction to peanuts. The slightest contact with peanuts or peanut
derivatives, usually peanut oil, could be fatal. To what lengths must
the food service go to accommodate the child? Is it sufficient for the
school food service to merely avoid obvious foods, such as peanut
butter, or must school food service staff research every ingredient and
additive in processed foods or regularly post all of the ingredients
used in recipes?

**Response:**

The school has the responsibility to provide a safe, non-allergic meal
to the child if it is determined that the condition is disabling. To do
so, school food service staff must make sure that all food items offered
to the allergic child meet prescribed guidelines and are free of foods
which are suspected of causing the allergic reaction.

This means that the food labels or specifications will need to be
checked to ensure that they do not contain traces of such substances. In
some cases, the labels will provide enough information to make a
reasonable judgment possible. If they do not provide enough information,
it is the responsibility of the school food service to obtain the
necessary information to ensure that no allergic substances are present
in the foods served.

In some cases, it may be necessary to contact the supplier or the
manufacturer or to check with the State agency. Private organizations,
such as the Food Allergy and Anaphylaxis Network (see **Appendix D**),
may also be consulted for information and advice. It is also wise to
check with parents about certain foods and even provide them with
advance copies of menus.

The general rule in these situations is to exercise caution at all
times. Do not serve foods to children at risk for anaphylactic
reactions, if you do not know what is in those foods. It is important to
recognize that a child may be provided a meal, which is equivalent to
the meal served to other children, but not necessarily the same meal.

25

Sometimes, it will be advisable to prepare a separate meal \"from
scratch\" using ingredients that are allowed on the special diet rather
than serving a meal using processed foods.

**Situation 5:**

A child has a health condition that does not meet the definition of
\"disability\" set forth in the legislation and regulations. For
example, the child is overweight (but not "morbidly\" so), or the child
has elevated blood cholesterol. Is the school obligated to accommodate
the special dietary needs of this child?

**Response:**

The school may make substitutions for children who are not considered to
be disabled, but who should avoid certain foods. However, the school is
not required to do so. When the school does elect to accommodate
children without disabilities, it must have a supporting statement,
signed by a recognized medical authority on file.

In most cases, the dietary needs of such children can be accommodated at
the food service site in schools and institutions where a variety of
nutritious foods are available for individual choice. In addition, the
\"offer versus serve\" provision which allows students the option to
decline one or two foods in the normal (reimbursable) school meal may be
of assistance in accommodating an individual\'s particular diet.

**Situation 6:**

A child\'s parents have requested that the school prepare a strict
vegetarian diet for their child based on a statement from a health food
store \"nutrition advisor\" who is not a licensed physician. Must the
school comply with this request?

**Response:**

No. The school is responsible only for accommodating those conditions
meeting the definition of disability as described in 7 CFR Part 15b.
Schools are not required to make food substitutions based on food
choices of a family or child regarding a healthful diet.

26

**C. RESPONSIBILITIES OF FOOD SERVICE MANAGEMENT COMPANIES (FSMC) AND
OTHER FOOD SERVICE OPERATIONS**

**Situation 7:**

A school district has contracted with a FSMC to operate the school\'s
food service. Is the FSMC obligated to accommodate children with
disabilities?

**Response:**

Yes. The school is always required to ensure that any benefits available
for the general school population are equally available to children with
disabilities. Consequently, accommodations for these children must be
made regardless of whether the school district operates the food service
itself or contracts with an FSMC to do so.

However, as a procurement issue, accommodations for children with
disabilities must be included in the contract. School food authorities
that do not have any need for special dietary accommodations at the time
a FSMC bid is prepared should still include sufficient information in
the bid to ensure that the FSMC is aware that dietary accommodations may
be required during the term of the contract.

**Situation 8:**

Some schools purchase items from nationally recognized fast-food chains
and sell these items on an \"a la carte\" basis. These items are
frequently sold in a setting such as a kiosk which uses the chain\'s
logo or otherwise advertises the product. What obligation, if any, does
the fast-food chain have to provide alternative meals?

**Response:**

When the school purchases and sells the product itself, the fast-food
chain incurs no more obligations than any other wholesaler or retailer
of food products. Consequently, it is important that parents, school
food service staff, and other involved school personnel identify and
discuss the particular needs of children with special needs and take
steps to ensure such children, especially very young children, do not
purchase \"a la carte\" items which can be harmful to them.

27

Technically, food items sold strictly on an \"a la carte\" basis are not
part of a reimbursable meal. The food items are not subject to program
regulations as long as they do not belong to any of the categories of
foods of minimal nutritional value. The fast-food chain may not be under
the obligation to provide alternate food items, unless this is
explicitly stated in its contract to vend food items to the school.

However, schools would be well advised to obtain from the food chain or
vendor(s) specific information on the ingredients in the food products
purchased, particularly, if there are children diagnosed at risk of
severe food allergies who are participating in the food service.
Furthermore, the school may want to consider including such product
information as a specification in its contract with the chain or vendor

**D. FEEDING IN SEPARATE FACILITIES -- GENERALLY**

**NOT ACCEPTABLE**

**Situation 9:**

A school wishes to serve meals to children with disabilities in an area
separate from the cafeteria where the majority of school children eat.
May the school establish a separate facility for these children?

**Response:**

Federal civil rights legislation, including Section 504 of the
*Rehabilitation Act of 1973*, IDEA, and Title II of the ADA, requires
that in providing for or arranging for the provision of nonacademic
services and extracurricular activities, including meals, school
districts must ensure that students with disabilities participate along
with children without disabilities to the maximum extent appropriate to
the needs of students with disabilities.

In general, children with disabilities must be allowed to participate
with other children to the maximum extent appropriate. In this way, the
child has the opportunity to interact with and learn from children
without disabilities. The school must not segregate children with
disabilities on the basis of convenience to the school or to other
children.

28

In rare instances, however, it may be to a child\'s benefit to be served
separately. For instance, a child with severe motor disabilities may be
able to receive individualized attention in handling eating utensils if
a special education specialist is able to work with them outside the
cafeteria.

Nevertheless, it must be emphasized that 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. Schools cannot
segregate children with disabilities based on the convenience of the
school or other children.

**E. TEMPORARY DISABILITIES**

**Situation 10:**

A child was involved in an accident and underwent major oral surgery. As
a result, the child will be unable to consume food for a period of time
unless the texture is modified. Is the school obligated to make this
accommodation even though the child will not be permanently disabled?

Response:

A child's whose disability restricts their diet must be provided
substitutions or modifications to foods regardless of the duration of
the disability.

**F. COMPLICATED FEEDINGS**

**Situation 11:**

A child enrolled in the school will require tube feedings. Is the food
service only required to pay for and provide the food, or are the costs
for the school nurse, an aide or a specially trained professional to
administer the feeding also assigned to the food service?

**Response:**

It must be emphasized that the overall responsibility for accommodating
children with disabilities rests with the school district. The school
district administration is responsible for allocating the district's
costs of accommodating children with disabilities and for deciding which
personnel will work with individual children.

29

In most instances involving food substitutions, the school food service
account will be used to pay the cost of special food and food
preparation equipment and 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 to purchase a blender or food processor, and to have the meal
prepared by the food service staff.

In the case of more delicate operations, such as tube feeding, it is
advisable that commercial nutritive formulas, prescribed by a licensed
physician, and specially designed for tube feedings, be used rather than
a school blenderized formula, which may be subject to spoilage and 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 special trained aides
who regularly work with the child.

Special labor costs may be covered through special education funds, if
the child has an IEP. If the child does not have an IEP, these costs
may, as appropriate, be charged in part to the food service account, or
may be assigned to the school district's general fund or to other
funding sources.

**Situation 12:**

A child with a disability is on a number of medications. The physician's
statement is well defined and includes menus with specific foods. If a
situation arises where specific foods are out of stock, should school
food service make substitutions on an \"as necessary\" basis?

**Response:**

No. School food service staff cannot decide what substitutions are
appropriate for a given child. Food service staff should not choose the
substitutions themselves because a child may be on a specific
medication, which could interact in a negative way with a particular
food item.

Ideally, a list of appropriate substitutions should accompany the menus
and the foods should be on hand on a regular basis. If such a list is
not available, school food service staff must ask parents to obtain from
the child's physician (or the individual who planned the child\'s menus)
a list of those foods that may be substituted.

[]{.mark}

30

**G. SCHOOL FOOD SERVICE ACCOUNT**

**Situation 13:**

A child with a disability needs to consume six cans of a nutritional
supplement during the school day: two cans at breakfast, one can as a
mid-morning snack, two cans at lunch, and one can as a mid-afternoon
snack. The cost of the breakfast and lunch supplements is allowable food
service expenses. If the school chooses to offer the additional
supplement at the mid-morning and mid-afternoon snack period, are these
allowable costs to the food service account?

**Response:**

Yes. While it is not required that these costs be charged to the
nonprofit school food service account, these supplements are a
legitimate charge to the food service account.

**Situation 14:**

A child with a disability requires the services of the school nurse for
assistance in feeding at lunch. Can the food service account be billed
for the services of non-food service personnel such as the school nurse
or special aide who may be assisting in the feeding of the child or
other nutrition related activity?

**Response:**

Yes. The services of any personnel necessary to the food service can be
paid by the food service account on a pro rata basis. It must be
emphasized, however, that the food service account may only pay for the
amount of time that the person actually spends on activities related to
the school food service. If a school nurse spends one hour per day
feeding a child with a special need, then only that portion of his/her
salary can be charged to the food service account, not the entire
salary. If the child is receiving special education and the child\'s IEP
includes a nutrition or feeding component, special education funds may
be available to the school to provide required services for the child.

31

**H. DOCUMENTATION**

**Situation 15:**

The physician\'s statement only specifies the medical disability, not
the required food substitutions. What should the food service director
do?

**Response:**

An appropriate school official (such as the food service director, food
service manager or school nurse) must ask parents to obtain more written
information from the physician concerning the substitutions or
modifications the child requires. If difficulties arise in obtaining the
needed information, the parent(s) should be advised of the problem and
asked to work with the school to obtain a complete medical statement for
the child. It is important that the family understand that the school is
unable to provide food substitutions or modifications without an
adequate diet order or diet prescription.

In some cases, it may be appropriate and helpful for the physician to
provide a written referral to a registered dietitian or other qualified
professional for diet substitutions. For further guidance or referral to
a registered dietitian, school food service directors may contact their
State agency.

32

**VI. SAMPLE DOCUMENTATION**

**FOR SPECIAL DIETARY NEEDS**

It is important to document the special nutritional needs of children
requiring dietary modifications. Keeping a record will protect the
school and minimize misunderstandings. The medical statement does not
have to be renewed each year if there are no changes in the diet order.
Be sure to note and date any changes in the child's medical condition or
diet order.

**A**. **EATING/FEEDING EVALUATION**

*Figure 1* includes a sample Eating and Feeding Evaluation: Children
with Special Needs. This form should be completed by a parent, a
physician, or other recognized medical authority.

**B. INFORMATION CARD**

*Figure 2* gives an example of an information card, which can be used
daily by school food service staff in the kitchen to prepare meals for
the children who have special dietary or medical needs.

(The Information Card and the Eating/Feeding

Evaluation Form were adapted, with permission,

from forms developed by Susan Woods, R.D., for

Bibb County Schools in Georgia.)

33

FIGURE 1. EATING AND FEEDING EVALUATION: CHILDREN WITH SPECIAL NEEDS

+--------------------------------------------+-----+---+---+-----+--------+
| PART A                                     |     |   |   |     |        |
+--------------------------------------------+-----+---+---+-----+--------+
| Student's Name                             |     | A |   |     |        |
|                                            |     | g |   |     |        |
|                                            |     | e |   |     |        |
+--------------------------------------------+-----+---+---+-----+--------+
| Name of School                             | Gr  |   |   | Cla |        |
|                                            | ade |   |   | ssr |        |
|                                            | Le  |   |   | oom |        |
|                                            | vel |   |   |     |        |
+--------------------------------------------+-----+---+---+-----+--------+
| Does the child have a disability? If Yes,  |     |   | Y |     | No     |
| describe the major life activities         |     |   | e |     |        |
| affected by the disability.                |     |   | s |     | No     |
|                                            |     |   |   |     |        |
| Does the child have special nutritional or |     |   | Y |     |        |
| feeding needs? If Yes, complete Part B of  |     |   | e |     |        |
| this form and have it signed by a licensed |     |   | s |     |        |
| physician.                                 |     |   |   |     |        |
+--------------------------------------------+-----+---+---+-----+--------+
| If the child is not disabled, does the     |     |   | Y |     | No     |
| child have special nutritional or feeding  |     |   | e |     |        |
| needs? If Yes, complete Part B of this     |     |   | s |     |        |
| 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                         |     |   | D |     |        |
|                                            |     |   | a |     |        |
|                                            |     |   | t |     |        |
|                                            |     |   | e |     |        |
|                                            |     |   | : |     |        |
+--------------------------------------------+-----+---+---+-----+--------+
| Physician or Medical Authority's Signature |     |   | D |     |        |
|                                            |     |   | a |     |        |
|                                            |     |   | t |     |        |
|                                            |     |   | e |     |        |
|                                            |     |   | : |     |        |
+--------------------------------------------+-----+---+---+-----+--------+

34

## FIGURE 2. INFORMATION CARD

+-----------------------------------+-----------------+-----------------+
| 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:               | Additional      |                 |
|                                   | Contact:        |                 |
| Name                              |                 |                 |
|                                   | Name            |                 |
| Telephone                         |                 |                 |
|                                   | Telephone       |                 |
| Fax                               |                 |                 |
|                                   | Fax             |                 |
+-----------------------------------+-----------------+-----------------+
| School Food Service               |                 | Date:           |
| Representative/Person Completing  |                 |                 |
| Form:                             |                 |                 |
|                                   |                 |                 |
| Title                             |                 |                 |
|                                   |                 |                 |
| Signature                         |                 |                 |
+-----------------------------------+-----------------+-----------------+

35

VII. **GLOSSARY**

**AMERICANS WITH DISABILITIES ACT (ADA)**

Comprehensive legislation, signed into law on July 26, 1990, that
creates new rights and extends existing rights for Americans with
disabilities. Title II of the Act is especially significant for the
school nutrition programs, as it requires equal availability and
accessibility in State and local government programs and services,
including public schools.

**ANAPHYLAXIS/ANAPHYLACTIC REACTION**

A rare but potentially fatal condition in which several different parts
of the body experience food-allergic reactions at the same time.
Symptoms may progress rapidly and include severe itching, hives,
sweating, swelling of the throat, breathing difficulties, lowered blood
pressure, unconsciousness and even death.

**DISABILITY**

Under Section 504 of the *Rehabilitation Act of 1973* and the *Americans
with Disabilities Act*, \"person with a disability\" means any person
who has a physical or mental impairment which substantially limits one
or more major life activities, has a record of such an impairment, or is
regarded as having such an impairment. The term \"physical or mental
impairment\" includes, but is not limited to, such diseases and
conditions as orthopedic, visual, speech, and hearing impairments;
cerebral palsy; epilepsy; muscular dystrophy; multiple sclerosis;
cancer; heart disease; metabolic diseases such as diabetes and
phenylketonuria (PKU); food anaphylaxis; mental retardation; emotional
illness; and drug addiction and alcoholism. Major life activities
covered by this definition include caring for one\'s self, eating,
performing manual tasks, walking, seeing, hearing, speaking, breathing,
learning and working.

36

Under the *Individuals with Disabilities Education Act* (IDEA), the term
\"disability\" refers to specified physical, mental, emotional, or sense
impairments, which adversely affect a child\'s educational performance.
Thirteen recognized disability categories, which establish a child's
need for special education and related services, are listed in IDEA.
These disabilities include autism; deaf-

blindness; deafness or other hearing impairments; mental retardation;
orthopedic impairments; other health impairments due to acute health
problems (such as a heart condition, epilepsy, or tuberculosis);
emotional disturbance; specific learning disabilities; speech or
language impairment; traumatic brain injury; visual impairment,
including blindness, which adversely affects a child\'s educational
performance.

**FOOD ALLERGY**

Hypersensitivity from an abnormal response of the body\'s immune system
to food or food additives that would otherwise be considered harmless.
Many of the true food allergy symptoms often resemble allergic reactions
to other substances, such as penicillin, drugs, bee stings, hives and
itching.

**FOOD INTOLERANCE**

An adverse food-induced reaction that does not involve the body\'s
immune system. Lactose intolerance is one example of a food intolerance.
A person with lactose intolerance lacks an enzyme that is needed to
digest milk sugar. When milk products are consumed symptoms such as gas,
bloating, and abdominal pain may occur.

**FREE APPROPRIATE PUBLIC EDUCATION (FAPE)**

Under the *Individuals with Disabilities Education Act ,* FAPE means
special education and related services provided under public supervision
and direction, in conformity with an individualized education program
(IEP), and at no cost to parents. In appropriate situations, nutrition
services could be deemed \"special education\" (specially designed
instruction) or a \"related service\" (support services required to
assist a child with a disability to benefit from special education).

37

# INDIVIDUALS WITH DISABILITIES EDUCATION ACT 

**(IDEA)**

Formerly the *Education of the Handicapped Act*, originally enacted in
1975, IDEA includes Part B, the basic grants to States program, which
provides Federal funds to assist States and school districts in making a
free appropriate public education available to eligible students with
specified disabilities.

**INDIVIDUALIZED EDUCATION PROGRAM (IEP)**

The Individualized Education Program or IEP means a written statement
for a child with a disability that is developed, reviewed, and revised
in a meeting in accordance with the IDEA and its implementing
regulations. The IEP is the cornerstone of the student's educational
program that contains the program of special education and related
services to be provided to a child with a disability covered under the
IDEA.

**NOTE:** Some states supplement the IEP with a written statement
specifically designed to address a student's nutritional needs. Other
states employ a "Health Care Plan" to address the nutritional needs of
their students. For ease of reference the term "IEP" is used to reflect
the IEP as well as any written statement designating the required
nutrition services.

**OSTEOPATHIC PHYSICIAN OR DOCTOR OF**

**OSTEOPATHIC MEDICINE**

A fully trained physician who is licensed by the State to prescribe
medication or to perform surgery. The American Medical Association
includes osteopathic physicians as equal members with M.D.s. The
majority of doctors of osteopathic medicine are primary care physicians.

38

# SPECIAL DIETARY NEEDS

An individual who does not have a disability, as defined in 7 CFR 15(b),
but is unable to consume a particular food because of a medical or other
special dietary condition is considered to have a special dietary need.
The individual\'s special dietary need and the needed substitution(s)
must be supported by a medical statement from a licensed medical
authority or other appropriate health professional as designated by the
State. A person with special dietary needs may have a food allergy or
intolerance (for example, lactose intolerance) but does not have
life-threatening (anaphylactic) reactions when exposed to food(s) to
which he/she is allergic.

**RECOGNIZED MEDICAL AUTHORITY**

Physicians, physician assistants, nurse practitioners; or other
professionals specified by the State agency. See *FNS Instruction 783-2,
Revision 2, Meal Substitutions for Medical or Other Special Dietary
Reasons*.

**REGISTERED DIETITIAN (R.D.)**

A nutrition professional who has earned a B.S. or B.A. degree, met basic
academic and clinical training requirements, and passed the qualifying
examination for professional registration for dietetics. The
registration program is maintained by the Commission on Dietetic
Registration of the American Dietetic Association. R.D.s can answer
questions on special diets, menu planning, and related topics and
conduct a nutritional assessment. An R.D. may work with the physician
and school staff to assist in meeting a child\'s special nutritional
needs and to ensure that menus are in compliance with the physician\'s
diet order.

# REHABILITATION ACT OF 1973

The principal Federal legislation aimed at promoting the employment and
independent living of people with disabilities. Section 504 of Title V
of this legislation prohibits discrimination against qualified persons
with disabilities in the programs or activities (including hiring
practices) of any organization receiving Federal financial assistance.

39

**APPENDICES**

40

##### 

# Appendix A

+-----------------------------------------+----------------------------+
| UNITED STATES DEPARTMENT OF AGRICULTURE | FNS INSTRUCTION 783-2      |
|                                         |                            |
| Food and Nutrition Service              | REV. 2                     |
|                                         |                            |
| 3101 Park Center Drive                  |                            |
|                                         |                            |
| Alexandria, VA 22302                    |                            |
+-----------------------------------------+----------------------------+

ACTION BY: Regional Directors

Special Nutrition Programs

SOURCE CITATION: Rehabilitation Act of 1973, Section 504;

> 7 CFR Part 15b; 7 CFR Sections 210.10(i)(1), 210.23(b),
>
> 215.14, 220.8(f), 225.16(g)(4), and 226.20(h)

**Meal Substitutions for Medical**

**or Other Special Dietary Reasons**

Child Nutrition Program regulations require participating school food
authorities, institutions and sponsors to offer to all participants
breakfasts, lunches, suppers, supplements and milk which meet the meal
patterns identified in the Program regulations. Departmental regulations
further [require]{.underline} substitutions to the standard meal
patterns for participants who are considered handicapped under 7 CFR
Part 15b and whose handicap restricts their diet; and
[permit]{.underline} substitutions for other participants who are not
handicapped but are unable to consume regular Program meals because of
medical or other special dietary needs. The provisions requiring
substitutions for handicapped participants respond to the requirements
of Section 504 of the Rehabilitation Act of 1973 and to the U.S.
Department of Agriculture\'s implementing regulations, 7 CFR Part 15b,
which provide that no otherwise qualified handicapped individuals shall,
solely on the basis of handicap, be excluded from participation in, be
denied benefit of, or subjected to discrimination under any program or
activity receiving Federal financial assistance.

This Instruction outlines the policy for food substitutions and other
modifications in the meal patterns necessary to meet the dietary
requirements of Program participants with handicaps and with other
special dietary needs. School food authorities, institutions and
sponsors are required to offer Program meals to participants with
handicaps whenever Program meals are offered to the general populations
served by the Programs. School food authorities, institutions and
sponsors should be aware that the

+-----------+-------------------------+-----------------+-------------+
| DIST      | MANUAL MAINTENANCE      | RESPONSIBLE FOR | PAGE 1      |
| RIBUTION: | INSTRUCTIONS            | PREPARATION AND |             |
|           |                         | MAINTENANCE:    | 10-14-94    |
| 5,        | Remove FNS Instruction  |                 |             |
| 6,7,11,12 | 783-2, Rev. 1, from     | CND-100         |             |
|           | Manual. Insert this     |                 |             |
|           | Instruction             |                 |             |
+-----------+-------------------------+-----------------+-------------+

41

FNS INSTRUCTION 783-2

REV. 2

Individuals with Disabilities Education Act (IDEA) imposes requirements
on States which may affect them, including the service of meals even
when such service is not required by the Child Nutrition Programs.

For example, the individualized education program developed for a child
under the IDEA may require a meal to be served outside of the regular
meal schedule for Program meals or may require a breakfast to be served
in a school food authority which does not participate in the School
Breakfast Program. While the school food authority, institution or
sponsor may not claim these meals as Program meals, it may use the same
food service facilities or food service management company to provide
these meals as it uses to provide Program meals, and Program funds may
be used to pay for the costs associated with the IDEA-required meals.
Inquiries regarding the IDEA\'s requirements should be directed to the
U.S. Department of Education, the Agency responsible for the IDEA\'s
administration and enforcement.

School food authorities, institutions and sponsors may also have
responsibilities under the Americans with Disabilities Act (ADA).
Inquiries regarding a school food authority\'s, institution\'s or
sponsor\'s responsibilities under the ADA should be directed to the U.S.
Department of Education, the agency responsible for the enforcement of
the ADA\'s requirements in elementary and secondary education systems.

I HANDICAPPED PARTICIPANTS

\"Handicapped person\" is defined in 7 CFR 15b.3(i) as any person who
has \"a physical or mental impairment which substantially limits one or
more major life activities, has a record of such impairment, or is
regarded as having such an impairment." (See Exhibit A, 7 CFR 15b.3.)
\"Major -life activities\" are defined in 7 CFR 15b.3(k) as \"functions
such as caring for one\'s self, performing manual tasks, walking,
seeing, hearing, speaking, breathing, learning and working." School food
authorities, institutions and sponsors participating in the Child
Nutrition Programs are required to make substitutions or modifications
to the meal patterns for those participants with handicaps who are
unable to consume the meals offered to nonhandicapped participants.

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42

FNS INSTRUCTION 783-2

REV.2

\(I\)

Determinations of whether or not a participant has a handicap which
restricts his or her diet are to be made on an individual basis by a
licensed physician. (Licensed physicians include Doctors of Osteopathy
in many states.) The physician\'s medical statement of the
participant\'s handicap must be based on the regulatory criteria for
\"handicapped person\" defined in 7 CFR Part 15b.3(i) and contain a
finding that the handicap restricts the participant\'s diet. In those
cases in which the school food authority, institution or sponsor has
consulted with the physician issuing the statement and is still unclear
whether the medical statement meets the regulatory criteria, the school
food authority, institution or sponsor may consult the State agency.

A participant whose handicap restricts his or her diet shall be provided
substitutions in foods only when supported by a statement signed by a
licensed physician. The medical statement shall identify:

A. The participant\'s handicap and an explanation of why the handicap
restricts the participant\'s diet;

B. The major life activity affected by the handicap; and

C. The food or foods to be omitted from the participant\'s diet, and the
food or choice of foods that must be substituted.

If the handicap would require caloric modifications or the substitution
of a liquid nutritive formula, for example, this information must be
included in the statement. If the handicapped participant requires only
textural modifications to the regular Program meal, as opposed to a meal
pattern modification, the medical statement is recommended, but not
required. In such cases, the purpose of the statement is to assist the
school food authority, institution or sponsor in providing the
appropriate textural modifications. Unless otherwise specified by the
physician, the meals modified for texture will consist only of food
items and quantities specified in the regular menus.

The State agency should make 7 CFR 15b.3 (Exhibit A) available to school
food authorities, institutions and sponsors. The school food authority,
institution or sponsor should also provide parents or guardians with 7
CFR Part 15b.3, so that their physicians may correctly assess whether an
individual\'s handicap meets the regulatory criteria. School food
authorities, institutions and sponsors should use the services of a
Registered Dietitian to assist in implementing the medical statement, as
appropriate.

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43

FNS INSTRUCTION 783-2

REV. 2

\(I\)

Generally, participants with food allergies or intolerances, or obese
participants are not \"handicapped persons\", as defined in 7 CFR
15b.3(i), and school food authorities, institutions and sponsors are not
required to make substitutions for them. However, when in the
physician\'s assessment food allergies may result in severe,
life-threatening reactions (anaphylactic reactions) or the obesity is
severe enough to substantially limit a major life activity, the
participant then meets the definition of \"handicapped person\", and the
food service personnel must make the substitutions prescribed by the
physician.

\(II\)

PARTICIPANTS WITH OTHER SPECIAL DIETARY NEEDS

School food authorities, institutions or sponsors may, at their
discretion, make substitutions for individual participants who are not
\"handicapped persons\", as defined in 7 CFR Part 15b.3(i), but who are
unable to consume a food item because of medical or other special
dietary needs. Such substitutions may only be made on a case-by-case
basis when supported by a statement signed by a recognized medical
authority. In these cases, recognized medical authorities may include
physicians, physician assistants, nurse practitioners or other
professionals specified by the State agency.

For these nonhandicapped participants, the supporting statement shall
include:

A. An identification of the medical or other special dietary need which
restricts the participant\'s diet; and

B The food or foods to be omitted from the participant\'s diet, and the
food or choice of foods that may be substituted.

School food authorities, institutions and sponsors are not required to
make substitutions for participants whose conditions do not meet the
definition of \"handicapped person\" set forth in 7 CFR 15b.3(i). For
example, individuals who are overweight or have elevated blood
cholesterol generally do not meet the definition of handicapped person,
and thus school food authorities, institutions, and sponsors are not
required to make meal substitutions for them. In fact, in most cases,
the special dietary needs of nonhandicapped participants may be managed
within the normal Program meal service when a well-planned

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44

FNS INSTRUCTION 783-2

REV. 2

\(II\)

variety of nutritious foods is available to children, and/or \"offer
versus serve" is available and implemented.

\(III\) REIMBURSEMENT AND AVAILABILITY OF SUBSTITUTIONS

Reimbursement for meals served with an authorized substitute food to
handicapped participants or to participants with other special dietary
needs shall be claimed at the same reimbursement rate as meals which
meet the meal pattern. Furthermore, there shall not be a supplementary
charge for the substituted food item(s) to either a handicapped
participant or to a participant with other special dietary needs. 7 CFR
15b.26(d)(1) specifies that, in providing food services, recipients of
Federal financial assistance \"may not discriminate on the basis of
handicap\" and \"shall serve special meals, at no extra charge, to
students whose handicap restricts their diet.\" While any additional
costs for substituted foods are considered allowable Program costs, no
additional Child Nutrition Program reimbursement is available. Sources
of supplemental funding may include special education funds (if the
substituted food is specified in the child\'s individualized education
program); the general account of the school food authority, institution
or sponsor; or, for school food authorities, the nonprofit school food
service account.

\(IV\) ACCESSIBILITY

7 CFR 15b.26(d)(2) provides: \"Where existing food service facilities
are not completely accessible and usable, recipients may provide aides
or use other equally effective methods to serve food to handicapped
persons.\" The school food authority, institution or sponsor is
responsible for the accessibility of food service sites and for ensuring
the provision of aides, where needed. As with additional costs for
substituted foods, any additional costs for adaptive feeding equipment
or for aides are considered allowable costs. However, no additional
Child Nutrition Program reimbursement is available. Sources of
supplemental funding may include special education funds (if specified
in the child\'s individualized education program); the general account
of the school food authority, institution or sponsor; or, for school
food authorities, the nonprofit school food service account.

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45

FNS INSTRUCTION 783-2

REV. 2

\(IV\)

7 CFR 15b.26(d)(2) further provides that recipients provide all food
services in the most integrated setting appropriate to the needs of the
handicapped persons as required by 7 CFR 15b.23(b).

That section requires Program recipients to ensure that handicapped
persons participate with nonhandicapped persons to the maximum extent
appropriate to the needs of the handicapped person in question.

V COOPERATION

When implementing the guidelines of this Instruction, food service
personnel should work closely with the parent(s) or responsible family
member(s) and with all other school, child care, medical and community
personnel who are responsible for the health, well-being and education
of participants with handicaps or with other special dietary needs to
ensure that reasonable accommodations are made to allow such
individuals', participation in the meal service. This cooperation is
particularly important when accommodating children or elderly adults
whose handicapping conditions require significant modifications or
personal assistance.

ALBERTA C. FROST

Director

Child Nutrition Division

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46

#### 7 CFR Part 15b Exhibit A

+------------------------+----------------------+---------------------+
| §15b.3 Definitions     | reduced              | \(n\) "Qualified    |
|                        | consideration or in  | handicapped person" |
| As used in this part,  | recognition of the   | (used synonymously  |
| the term or phrase:    | public nature of the | with "otherwise     |
|                        | recipient's program  | qualified           |
| \(a\) "The Act" means  | or activity; and     | handicapped         |
| the Rehabilitation Act |                      | individual") means: |
| of 1973, Public Law    | \(ii\) Proceeds from |                     |
| 93-112, 87 Stat. 390   | a subsequent sale,   | \(1\) With respect  |
| (1973), as amended by  | transfer or lease of | to employment, a    |
| the Rehabilitation Act | Federal property if  | handicapped person  |
| Amendments of 1974,    | the Federal share of | who, with           |
| Public Law 93-651, 89  | its fair market      | reasonable          |
| Stat. 2 (1974) and     | value is not         | accommodation, can  |
| Public Law 93-516, 88  | returned to the      | perform the         |
| Stat. 1617 (1974) and  | Federal government.  | essential functions |
| the Rehabilitation,    |                      | of the job in       |
| Comprehensive Services | \(4\) Any other      | question, but the   |
| and Developmental      | thing of value.      | term does not       |
| Disabilities           |                      | include any         |
| Amendments of 1978,    | \(h\) "Facility"     | individual who is   |
| Public Law 95-602, 92  | means all or any     | an alcoholic or     |
| Stat. 2955 (1978). The | portion of           | drug abuser whose   |
| Act appears at 29      | buildings,           | current use of      |
| U.S.C. 701-794.        | structures,          | alcohol or drugs    |
|                        | equipment, roads,    | prevents such       |
| \(b\) \"Section 504"   | walks, parking lots, | individual from     |
| means section 504 of   | or other real or     | performing the      |
| the Act, 29 U.S.C.     | personal property or | duties of the job   |
| 794.                   | interest in such     | in question or      |
|                        | property.            | whose employment,   |
| \(c\) \"Education of   |                      | by reason of such   |
| the Handicapped Act"   | \(i\) "Handicapped   | current alcohol or  |
| means the Education of | person" means any    | drug abuse, would   |
| the Handicapped Act,   | person who has a     | constitute a direct |
| Public Law 92-230,     | physical or mental   | threat to property  |
| Title VI, 84 Stat. 175 | impairment which     | or the safety of    |
| (1970), as amended by  | substantially limits | others;             |
| the Education of the   | one or more major    |                     |
| Handicapped Amendments | life activities, has | \(2\) With respect  |
| of 1974, Public Law    | a record of such an  | to public           |
| 93-380, Title VI, 88   | impairment, or is    | preschool,          |
| Stat. 576, (1974), the | regarded as having   | elementary,         |
| Education for All      | such an impairment.  | secondary or adult  |
| Handicapped Children   |                      | educational         |
| Act of 1975, Public    | \(j\) \"Physical or  | services, a         |
| Law 94-142, 89 Stat.   | mental impairment"   | handicapped person, |
| 773 (1975), and the    | means (1) any        | (i) of an age       |
| Education of the       | physiological        | during which        |
| Handicapped Amendments | disorder or          | non-handicapped     |
| of 1977, Public Law    | condition, cosmetic  | persons are         |
| 95-49, 91 Stat. 230    | disfigurement, or    | provided such       |
| (1977). The Education  | anatomical loss      | services, (ii) of   |
| of the Handicapped Act | affecting one or     | an age during which |
| appears at 20 U.S.C.   | more of the          | it is mandatory     |
| 1401- 1461.            | following body       | under State law to  |
|                        | systems:             | provide such        |
| \(d\) \"Department"    | Neurological,        | services to         |
| means the Department   | musculoskeletal;     | handicapped         |
| of Agriculture and     | special sense        | persons, or (iii)   |
| includes each of its   | organs; respiratory, | to whom a State is  |
| operating agencies and | including speech     | required to provide |
| other organizational   | organs;              | a free appropriate  |
| units.                 | cardiovascular;      | public education    |
|                        | reproductive;        | under section 612   |
| \(e\) \"Secretary"     | digestive;           | of the Education of |
| means the Secretary of | genitourinary; hemic | the Handicapped     |
| Agriculture or any     | and lymphatic; skin; | Act; and            |
| officer or employee of | and endocrine; or    |                     |
| the Department to whom | (2) any mental or    | \(3\) With respect  |
| the Secretary has      | psychological        | to postsecondary    |
| delegated or may       | disorder, such as    | and vocational      |
| delegate the authority | mental retardation,  | education services, |
| to act under the       | organic brain        | a handicapped       |
| regulations of this    | syndrome, emotional  | person who meets    |
| part.                  | or mental illness,   | all academic and    |
|                        | and specific         | technical standards |
| \(f\) \"Recipient\"    | learning             | requisite to        |
| means any State or its | disabilities. The    | admission or        |
| political subdivision, | term "Physical or    | participation in    |
| any instrumentality of | mental impairment"   | the recipient's     |
| a State or its         | includes, but is not | education program   |
| political subdivision, | limited to, such     | or activity;        |
| any public or private  | diseases and         |                     |
| agency, institution,   | conditions as        | \(4\) With respect  |
| organization, or other | orthopedic, visual,  | to other services,  |
| entity, or any person  | speech, and hearing  | a handicapped       |
| to which Federal       | impairments;         | person who meets    |
| financial assistance   | cerebral palsy;      | the essential       |
| is extended directly   | epilepsy; muscular   | eligibility         |
| or through another     | dystrophy; multiple  | requirements for    |
| recipient, including   | sclerosis, cancer,   | the receipt of such |
| any successor,         | heart disease;       | services.           |
| assignee, or           | diabetes; mental     |                     |
| transferee of a        | retardation;         | \(o\) "Handicap"    |
| recipient, but         | emotional illness;   | means any condition |
| excluding the ultimate | and drug addiction   | or characteristic   |
| beneficiary of the     | and alcoholism.      | that renders a      |
| assistance.            |                      | person a            |
|                        | \(k\) "Major life    | handicapped person  |
| \(g\) "Federal         | activities" means    | as defined in       |
| financial assistance\" | functions such as    | paragraph (i) of    |
| or "assistance" means  | caring for one's     | this section.       |
| any grant, contract    | self, performing     |                     |
| (other than a          | manual tasks,        | \(p\) for purposes  |
| procurement contract   | walking, seeing,     | of §15b.18(d),      |
| or a contract of       | hearing, speaking,   | "Historic           |
| insurance or           | breathing, learning  | preservation        |
| guaranty), cooperative | and working.         | programs" means     |
| agreement, formula     |                      | programs receiving  |
| allocation, loan, or   | (l)"Has a record of  | federal financial   |
| any other arrangement  | such an impairment"  | assistance that has |
| by which the           | means has a history  | preservation of     |
| Department provides or | of, or has been      | historic properties |
| otherwise makes        | misclassified as     | as a primary        |
| available assistance   | having, a mental or  | purpose.            |
| in the form of:        | physical impairment  |                     |
|                        | that substantially   | \(q\) For purposes  |
| \(1\) Funds;           | limits one or more   | of §15b.18(e),      |
|                        | major life           | "Historic           |
| \(2\) Services of      | activities.          | properties" means   |
| Federal personnel;     |                      | those buildings or  |
|                        | \(m\) "Is regarded   | facilities that are |
| \(3\) Real and         | as having an         | eligible for        |
| personal Federal       | impairment" means,   | listing in the      |
| property or any        | (1) has a physical   | National Register   |
| interest in Federal    | or mental impairment | of Historic Places, |
| property, including:   | that does not        | or such properties  |
|                        | substantially limit  | designated as       |
| \(i\) A sale,          | major life           | historic under a    |
| transfer, lease or use | activities but that  | statute of the      |
| (on other than a       | is treated by a      | appropriate State   |
| casual or transient    | recipient as         | or local government |
| basis) of Federal      | constituting such a  | body.               |
| property for less than | limitation; (2) has  |                     |
| fair market value, for | a physical or mental | \(r\) For purposes  |
|                        | impairment that      | of §15b.18(d),      |
|                        | substantially limits | "Substantial        |
|                        | major life           | impairment" means a |
|                        | activities only as a | significant loss of |
|                        | result of the        | the integrity of    |
|                        | attitudes of others  | finished materials, |
|                        | towards such         | design quality or   |
|                        | impairments, or (3)  | special character   |
|                        | has none of the      | which loss results  |
|                        | impairments defined  | from a permanent    |
|                        | in paragraph (j) of  | alteration.         |
|                        | this section but is  |                     |
|                        | treated by a         | 47                  |
|                        | recipient as having  |                     |
|                        | such an impairment.  |                     |
+------------------------+----------------------+---------------------+

##### APPENDIX B

**USDA, Food and Nutrition Service**

# Regional Directors

+----------------------------------+-----------------------------------+
| Regional Director                | [Mid-Atlantic Regional            |
|                                  | States]{.underline}               |
| Mid-Atlantic Regional Office     |                                   |
| (MARO),                          | Delaware, Virginia, District of   |
|                                  | Columbia, Virgin Islands,         |
| USDA, FNS, SNP                   | Maryland, West Virginia, New      |
|                                  | Jersey,                           |
| Mercer Corporate Park            |                                   |
|                                  | Pennsylvania, Puerto Rico         |
| 300 Corporate Boulevard          |                                   |
|                                  |                                   |
| Robbinsville, NJ 08691-1598      |                                   |
|                                  |                                   |
| 609-259-5025                     |                                   |
+----------------------------------+-----------------------------------+
| Regional Director                | [Midwest Regional                 |
|                                  | States]{.underline}               |
| Midwest Regional Office (MWRO),  |                                   |
|                                  | Illinois, Indiana, Michigan,      |
| USDA, FNS, SNP                   | Minnesota, Ohio                   |
|                                  |                                   |
| 77 West Jackson Blvd             | Wisconsin                         |
|                                  |                                   |
| 20^th^ Floor                     |                                   |
|                                  |                                   |
| Chicago, IL 60604-3507           |                                   |
|                                  |                                   |
| 312-353-6664                     |                                   |
+----------------------------------+-----------------------------------+
| Regional Director                | [Mountain Plains Regional         |
|                                  | States]{.underline}               |
| Mountain Plains Regional Office  |                                   |
| (MPRO),                          | Colorado, South Dakota, Iowa,     |
|                                  | North Dakota,                     |
| USDA, FNS, SNP                   |                                   |
|                                  | Kansas, Utah, Missouri, Wyoming,  |
| 1244 Speer Boulevard             | Montana                           |
|                                  |                                   |
| Suite 903                        | Nebraska                          |
|                                  |                                   |
| Denver, CO 80204                 |                                   |
|                                  |                                   |
| 303-844-0300                     |                                   |
+----------------------------------+-----------------------------------+
| Regional Director                | [Northeast Regional               |
|                                  | States]{.underline}               |
| Northeast Regional Office        |                                   |
| (NERO),                          | Connecticut, Vermont, Maine,      |
|                                  | Massachusetts,                    |
| USDA, FNS, SNP                   |                                   |
|                                  | New Hampshire, New York, Rhode    |
| 10 Causeway Street               | Island                            |
|                                  |                                   |
| Room 501                         |                                   |
|                                  |                                   |
| Boston, MA 02222-1065            |                                   |
|                                  |                                   |
| 617-565-6370                     |                                   |
+----------------------------------+-----------------------------------+
| Regional Director                | [Southeast Regional               |
|                                  | States]{.underline}               |
| Southeast Regional Office        |                                   |
| (SERO),                          | Alabama, South Carolina, Florida, |
|                                  | Georgia, Kentucky, Tennessee,     |
| USDA, FNS, SNP                   | Mississippi, North Carolina       |
|                                  |                                   |
| 61 Forsyth Street, SW            |                                   |
|                                  |                                   |
| Room 8T36                        |                                   |
|                                  |                                   |
| Atlanta, GA 30303                |                                   |
|                                  |                                   |
| 404-562-1800                     |                                   |
+----------------------------------+-----------------------------------+
| Regional Director                | [Southwest Regional               |
|                                  | States]{.underline}               |
| Southwest Regional Office        |                                   |
| (SWRO),                          | Arkansas, Louisiana, New Mexico,  |
|                                  | Oklahoma,                         |
| USDA, FNS, SNP                   |                                   |
|                                  | Texas                             |
| 1100 Commerce Street             |                                   |
|                                  |                                   |
| Room 5C30                        |                                   |
|                                  |                                   |
| Dallas, TX 75242                 |                                   |
|                                  |                                   |
| 214-290-9800                     |                                   |
+----------------------------------+-----------------------------------+
| Regional Director                | [Western Regional                 |
|                                  | States]{.underline}               |
| Western Regional Office (WRO),   |                                   |
|                                  | Alaska, Oregon, American Samoa,   |
| USDA, FNS, SNP                   | Arizona, Washington, California,  |
|                                  | Guam, Hawaii, Trust Territories,  |
| 550 Kearny Street                | Idaho, Nevada, Commonwealth of    |
|                                  | the Northern Mariana Islands      |
| Room 400                         |                                   |
|                                  |                                   |
| San Francisco, CA 94108          |                                   |
|                                  |                                   |
| 415-705-2229                     |                                   |
+----------------------------------+-----------------------------------+

> 48

##### APPENDIX B(continued)

**Regional Civil Rights Offices**

+---------------------------------+------------------------------------+
| Regional Director MARO          | [Mid-Atlantic Regional             |
|                                 | States]{.underline}                |
| Civil Rights                    |                                    |
|                                 | Delaware, Virginia, District of    |
| Mercer Corporate Park           | Columbia, Virgin Islands,          |
|                                 | Maryland, West Virginia, New       |
| ## 300 Corporate Boulevard      | Jersey, Puerto Rico, Pennsylvania  |
|                                 |                                    |
| Robbinsville, NJ 08691-1598     |                                    |
|                                 |                                    |
| 609-259-5123                    |                                    |
+---------------------------------+------------------------------------+
| Regional Director MWRO          | [Midwest Regional                  |
|                                 | States]{.underline}:               |
| Civil Rights                    |                                    |
|                                 | Illinois, Wisconsin, Indiana,      |
| 77 West Jackson Blvd            | Michigan, Minnesota, Ohio          |
|                                 |                                    |
| 20^th^ Floor                    |                                    |
|                                 |                                    |
| Chicago, IL 60604-3507          |                                    |
|                                 |                                    |
| 312-353-3353                    |                                    |
+---------------------------------+------------------------------------+
| Regional Director MPRO          | [Mountain Plains Regional          |
|                                 | States]{.underline}:               |
| Civil Rights                    |                                    |
|                                 | Colorado, South Dakota, Iowa,      |
| 1244 Speer Boulevard            | North Dakota, Kansas, Utah,        |
|                                 | Missouri, Wyoming, Montana,        |
| Suite 903                       | Nebraska                           |
|                                 |                                    |
| Denver, CO 80204                |                                    |
|                                 |                                    |
| 303-844-0307                    |                                    |
+---------------------------------+------------------------------------+
| Regional Director NERO          | [Northeast Regional                |
|                                 | States]{.underline}                |
| Civil Rights                    |                                    |
|                                 | Connecticut, Vermont, Maine, Rhode |
| 10 Causeway Street              | Island,                            |
|                                 |                                    |
| Room 501                        | Massachusetts, New Hampshire, New  |
|                                 | York                               |
| Boston, MA 02222-1065           |                                    |
|                                 |                                    |
| 617-565-6424                    |                                    |
+---------------------------------+------------------------------------+
| Regional Director SERO          | [Southeast Regional                |
|                                 | States]{.underline}:               |
| Civil Rights                    |                                    |
|                                 | Alabama, South Carolina, Florida,  |
| 61 Forsyth Street, SW           | Georgia, Kentucky, Tennessee,      |
|                                 | Mississippi, North Carolina        |
| Room 8t36                       |                                    |
|                                 |                                    |
| Atlanta, GA 30303               |                                    |
|                                 |                                    |
| 404-562-1808                    |                                    |
+---------------------------------+------------------------------------+
| Regional Director SWRO          | [Southwest Regional                |
|                                 | States]{.underline}:               |
| Civil Rights                    |                                    |
|                                 | Arkansas, Louisiana, New Mexico,   |
| 1100 Commerce Street            | Oklahoma, Texas                    |
|                                 |                                    |
| Room 5-A-6                      |                                    |
|                                 |                                    |
| Dallas, TX 75242                |                                    |
|                                 |                                    |
| 214-290-9820                    |                                    |
+---------------------------------+------------------------------------+
| Regional Director WRO           | [Western Regional                  |
|                                 | States]{.underline}:               |
| Civil Rights                    |                                    |
|                                 | Alaska, Oregon, American Samoa,    |
| 550 Kearny Street               | Arizona, Washington, California,   |
|                                 | Guam, Hawaii, Trust Territories,   |
| Room 400                        | Idaho, Nevada, Commonwealth of the |
|                                 | Northern Mariana Islands           |
| San Francisco, CA 94108         |                                    |
|                                 |                                    |
| 415-705-1322                    |                                    |
+---------------------------------+------------------------------------+

> 49

### APPENDIX C

**U.S. Department of Health and Human Services**

**Regional Contacts**

# Region I

## Connecticut, Maine Massachusetts, New Hampshire, Rhode Island, Vermont

Boston Regional Office

John F. Kennedy Federal Building

Boston, MA 02203-0003

Medicaid Associate Regional Administrator 617-565-1223

EPSDT and MCH Regional Coordinator 617-565-1243

# Region II

New Jersey, New York Puerto Rico, Virgin Islands

New York Regional Office

26 Federal Plaza, Room 3800

New York, NY 10278-0063

Medicaid Associate Regional Administrator 212-264-2058

## EPSDT and MCH Regional Coordinator 212-264-3978

# Region III

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West
Virginia

Philadelphia Regional Office

## The Public Ledger Building

150 South Independence Mall West

Philadelphia, PA 19106

## Medicaid Associate Regional Administrator (EPSDT) 215-861-4220

MCH Regional Coordinator 215-861-4252

## **Region IV**

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South
Carolina, Tennessee

Atlanta Regional Office

## Atlanta Federal Center,Suite 4T20

61 Forsyth Street, SW

Atlanta, GA 30303-8909

Medicaid Associate Regional Administrator 404-562-7401

EPSDT and MCH Regional Coordinator 404-562-7465

50

> **APPENDIX C**

**U.S. Department of Health and Human Services**

**Regional Contacts**

# Region V

Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Chicago Regional Office

233 N. Michigan Ave., Suite 600

Chicago, IL 60601-5519

## Medicaid Associate Regional Administrator 312-353-2702

EPSDT and MCH Regional Coordinator 312-353-3721

## **Region VI**

## Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Dallas Regional Office

1301 Young St. Room 833, 8^th^. Fl.

Dallas, TX 75202

## Medicaid Associate Regional Administrator 214-767-6301

EPSDT and MCH Regional Coordinator 214-767-6497

# Region VII

Iowa, Kansas, Missouri, Nebraska

Kansas City Regional Office

Richard Bolling Federal Building

601 East 12^th^ Street

Kansas City, MO 64106-2808

Medicaid Associate Regional Administrator 816-426-5925

EPSDT and MCH Regional Coordinator 816-426-3406

# Region VIII

Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

## Denver Regional Office

Health Care Finance Administration

Division of Medicaid and State Operations

1600 Broadway, Suite 700

Denver, CO 80202

Medicaid Associate Regional Administrator 303-844-1977

EPSDT and MCH Regional Coordinator 303-844-2682

51

**APPENDIX C**

**U.S. Department of Health and Human Services**

**Regional Contacts**

# Region IX

American Samoa, Arizona, CNMI, Guam, California, Hawaii, Nevada

San Francisco Regional Office

75 Hawthorne Street

San Francisco, CA 94105-3901

## Medicaid Associate Regional Administrator 415-744-3568

## EPSDT Regional Coordinator 415-744-3596

Regional MCH Program Consultant

Federal Office Building

50 United Nations Plaza

San Francisco, CA 94102 415-744-3553

# Region X

Alaska, Idaho, Oregon, Washington,

Seattle Regional Office

2201 Sixth Avenue

Seattle, WA 98121-2500

Medicaid Associate Regional Administrator 206-615-2313

EPSDT and MCH Regional Coordinator 206-615-2343

52

**APPENDIX D**

# Voluntary and Professional

**Health Organizations**

+---------------------------------+------------------------------------+
| American Academy of Allergy,    | Cleft Palate Foundation            |
|                                 |                                    |
| Asthma, and Immunology          | 1-800-24-CLEFT                     |
|                                 |                                    |
| 1-800-822-2762                  | www.cleft.com                      |
|                                 |                                    |
| www.aaaai.org                   |                                    |
+---------------------------------+------------------------------------+
| American Academy of Pediatrics  | Easter Seals                       |
|                                 |                                    |
| 1-847-434-4000 (National        | 312-726-6200 (voice)\              |
| Headquarters)                   | 312-726-4258 (TTY)                 |
|                                 |                                    |
| www.aap.org                     | www.easter-seals.org               |
+---------------------------------+------------------------------------+
| American Cancer Society         | Epilepsy Foundation of America     |
|                                 |                                    |
| 1-800-ACS-2345                  | 1-800-EFA-1000                     |
|                                 |                                    |
| www.cancer.org                  | www.efa.org                        |
+---------------------------------+------------------------------------+
| American Diabetes Association   | Food Allergy & Anaphylaxis         |
|                                 | Network, Inc.                      |
| 1-800-DIABETES                  |                                    |
|                                 | 1-800-929-4040                     |
| www.diabetes.org                |                                    |
|                                 | www.foodallergy.org                |
+---------------------------------+------------------------------------+
| American Heart Association      | Muscular Dystrophy Association of  |
|                                 | America                            |
| 1-800-AHA-USA1                  |                                    |
|                                 | 1-800-572-1717                     |
| www.americanheart.org           |                                    |
|                                 | www.mdausa.org                     |
+---------------------------------+------------------------------------+
| Arthritis Foundation            | National Cystic Fibrosis           |
|                                 | Foundation                         |
| 1-800-283-7800                  |                                    |
|                                 | 1-800-FIGHT CF                     |
| www.arthritis. org              |                                    |
|                                 | www.cff.org                        |
+---------------------------------+------------------------------------+
| Association for Retarded        | Spina Bifida Association           |
| Citizens                        |                                    |
|                                 | of America                         |
| (The ARC)                       |                                    |
|                                 | 1-800-621-3141                     |
| National Headquarters           |                                    |
|                                 | www.sbaa.org                       |
| 301-565-3842                    |                                    |
|                                 |                                    |
| www.thearc.org                  |                                    |
+---------------------------------+------------------------------------+
| Autism Society of America       | United Cerebral Palsy Association  |
|                                 |                                    |
| 1-800-3-AUTISM                  | 1-800-USA5-UCP\                    |
|                                 | (TTY)202-973-7197                  |
| www.autism-society.org          |                                    |
|                                 | www.ucpa.org                       |
+---------------------------------+------------------------------------+
| Crohn's and Colitis Foundation  | 53                                 |
|                                 |                                    |
| of America, Inc.                |                                    |
|                                 |                                    |
| 1-800-343-3637                  |                                    |
|                                 |                                    |
| www.ccfa.org                    |                                    |
+---------------------------------+------------------------------------+