Skip To Main Content

Diet Modification Requests

North Polk CSD is to committed to serving healthy meals each day to all students. If your student requires a special diet or has a food allergy, please have your licensed medical provider complete the diet modification request form listed below. 

Diet Modification Request

Diet modification Request Spanish

Once complete, please send forms to:

North Polk Community Schools
Attn: Food Service Director
13930 NE 6th Street
Alleman, IA 50007

Diet Modification Question and Answer

  1. Does the Diet Modification Request Form need to be filled out annually? No. The Diet Modification Request Form does not have to be reviewed each year if there are no changes in the diet order (United States Food and Nutrition Service [USDA], 2001).
  2. Who are the licensed medical providers that can complete the form? Iowa defines a licensed medical provider who is able to treat medical patients and write a medical prescription as a licensed physician (MD, DO), physician’s assistant (PA), or advanced registered nurse practitioner (ARNP).
  3. What does, “substantially limit a major life function” mean? The Americans with Disabilities Act Amendments of 2008 [ADAAA] defines a disability that substantially limits a major life function as any impairment related to: caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, reading, concentrating, thinking sleeping, eating, lifting, bending, communicating, operation of major bodily functions, such as immune system, normal cell growth, digestive, bowel and bladder (34 C.F.R. §104.3 (j)(2)(i) and ADAAA (2008).
  4. In the school setting, what are additional steps for the Food Service Director to take when receiving a Diet Modification Form? Food service personnel are an integral part of the multi-disciplinary team in the child find process of Section 504. Best practice would be to provide a copy of the diet modification request form to the building 504 contact, district 504 coordinator, and the school nurse. Additionally, another best practice would be to request participation with 504 planning meetings that require any diet modifications.
  5. Why is the Diet Modification Form required for a nutritional program? Children with disability who require changes to the basic meal pattern (such as special supplements or substitutions) are required to provide documentation with accompanying instructions from a licensed medical provider. This is required to ensure that the modified meal is reimbursable, and to ensure that any meal modifications meet nutritional standards which are medically appropriate for the child (USDA, 2001).
  6. In the school setting, who should maintain the Diet Modification Forms? Food service personnel should maintain the original form because it is required program documentation related to reimbursement.
  7. Can additional charges be added for nutritional substitutions when accommodations rise up to level of a disability or are considered a diet modification? 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 (USDA, 2001).
  8. How does a food service program accommodate a nutritionally related religious preference? The Diet Modification Form addresses medical needs pertaining to a medical condition only. The Offer vs Serve Program is recommended for many situations where students may decline food items due to taste, tolerance, religious beliefs without completing a form. (e.g. If providing Offer vs Serve, a student with a milk intolerance may decline milk without completing a form. However, juice is no longer an acceptable substitution.)
  9. How should a school proceed with a parental request for a school to become “allergen-free” or provide an “allergen free” table for their child to sit at during school meals? It is a local decision. Additional information available: Center for Disease Control and Prevention [CDC] has published national comprehensive guidelines in 2013, “Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs”, to assist districts with managing food allergies in the school setting. This can be retrieved from: CDC - Food Allergies - Adolescent and School Health or