PLANILLA DE AUTORIZACION DE DIETA

PLANILLA DE AUTORIZACION DE DIETA
Declaración Médica Anual para Estudiantes
con Necesidades Nutricionales Especiales para las Comidas
de laFORM
Escuela
DIET ORDER
Annual
Medical
Statement
forlaStudents
withrequerida
Special Nutritional
Needs
School
Esta planilla provee
a Child
Nutrition
Services
información
para modificar
las for
comidas
enMeals
la escuela
This form gives Child Nutrition Services the information required for meal modifications at school
Steps
topara
Complete
Diet Order
Form
Pasos
Completar
ésta Planilla
Parent/Guardian,
complete
Part A. Sign
and date
(required
for processing).
1. 1.
Padre/Guardián,
completar
la Parte
A. form
Firmar
y colocar
la fecha en la
Authority,
complete para
Part B.ser
Print
name, sign and date form; stamp form with
2. Medical
planilla
(se requiere
procesada).
medical
office stamp
(required
for processing).
2.
Autoridad
Médica,
completar
la Parte B. Imprimir el nombre, la firma,
Child Nutrition
Services la planilla con el sello de
or email
form to:enCMS
3. Mail,
y fax,
colocar
la fecha
la planilla;
estampillar
668847 para ser procesada).
la oficina del médicoPO(seBox
requiere
3. Enviar la planilla porCharlotte,
correo,NC
fax28266
o correo electrónico a:
Phone (980)
343-6041 Fax (980) 343-6045
CMS Child Nutrition
Services
PO Box 668847specialdiets@cms.k12.nc.us
Services
complete Part C and forward processed form to the student’s
4. Child
Nutrition
Charlotte,
NCwill28266
school
cafeteria.
Teléfono (980) 343-6041 | Fax (980) 343-6045
form will be returned to parent/guardian.
5. Incomplete
specialdiets@cms.k12.nc.us
PART B. To be completed by Licensed Physician
Initial Diet Order for School Year ______ - 20______
Revision to Diet Order Form submitted for school year ______
STUDENT DIAGNOSIS OR CONDITION
Food Intolerance
Food Allergy
Life Threating Food Allergy Students with life threatening food
allergies must have an emergency action plan in place at school.
Ingestion
Contact
Inhalation
Check appropriate box:
4. Child Nutrition Services completará la parte C y regresará la planilla
PART
A. Toa labecafetería
completed
by Parent
/ Guardian
procesada
de la escuela
de su hijo.
Disability (Specify)
STUDENT INFORMATION
PARTE
A. Para ser completado porDiet
el Order
Padre
/ Guardián
Student
ID Number
for School
Year
Other (Specify)
20
INFORMACION DEL ESTUDIANTE
Last,
First, MI
Número
de ID del Estudiante
-20
Autorización de Dieta para el Año Escolar
20____- 20____
Date
of BirthPrimer nombre,
School
Attended
Apellido,
Inicial
Segundo nombre
Grade
Describe major life activities affected
FOOD TEXTURE MODIFICATION
Pureed
If needed check ONE:
Grado
Daytime Phone Number
lactose-free milk or
juice
Ice Cream
Yogurt
Recipes with any dairy listed as an ingredient
Mailing Address, City, State, Zip
Teléfono
EGG
E-mail Address
Dirección Residencial, Ciudad, Estado, Código Postal
Which meals provided
Electrónico
byCorreo
the School
Cafeteria
will the student eat?
Breakfast
Lunch comidas
¿Qué
provistas
por la
Snack
Fluid Milk. Substitute with
Cheese and recipes with cheese listed as an ingredient
Información del Padre/Guardián
Apellido, Primer Nombre
Chopped
FOOD(S) THAT SHOULD BE AVOIDED
Check all that apply:
DAIRY
Fecha de
NacimientoINFORMATION
Escuela a la que Atiende
PARENT
/ GUARDIAN
First, Last
Ground
Does the student have
an identified disability
(IEP or 504 Plan)?
Yes
No
¿Tiene
el Estudiante
WHEAT
Recipes with any wheat listed as an ingredient
My child has a
special diet and will
NOT eat food from
CMS cafeteria.
FISH OR SHELLFISH
Specific fish or seafood type
TREE NUTS
Food products identified as manufactured in a plant that also handles tree nuts
Mi hijo tiene una
una discapacidad
dieta especial y NO
Cafetería de la
identificada (IEP o
comerá de la cafet
Parent
/
Guardian
Signature
(required
for
processing)
Date
Escuela tomará el
Plan 504)?
ría de
CMS
estudiante?
X
□ Si
□
Desayuno
□ NoServices permission to speak with the Licensed
By □
signing
above I give Child Nutrition
□ Almuerzo
Medical
Doctor (MD) or recognized Medical Authority signing the Diet Order Form to
□ Merienda
discuss
the student’s dietary needs described in Part B of this form.
Firma del Padre / Guardián (se requiriere para ser procesado)
Fecha
CMS Cafeterias do not serve peanuts or products containing peanuts; therefore, a
diet order form only specifying a peanut allergy is not needed.
Con mi firma doy permiso a Child Nutrition Services para hablar con el Médico o
Monthly
menu
with carbohydrate
content
in la
grams
anddemajor
food allergens
is posted
Autoridad
Médica
Reconocida que
firman
planilla
Autorización
de Dieta
para discutir
las necesidades alimenticias del estudiante descritas
en la Parte
B de esta
planilla.
at
http://www.cms.k12.nc.us/cmsdepartments/cns.
A completed
Diet Order
Form
is not
required if above information is sufficient for parent/guardian to manage a student's
• Las cafeterías de CMS no sirven productos de maní o que contengan maní; por lo tanto
dietno
at se
school.
necesitará una planilla de autorización de dieta que especifique solamente alergia al
Whole eggs such as scrambled eggs or hard cooked eggs
Recipes with any egg listed as an ingredient
CORN
Whole corn such as corn kernels, tortilla chips, corn muffin
Recipes with corn / corn products listed as an ingredient
OTHER
Other, specify if it is a cooked ingredient or when consumed fresh
LICENSED PHYSICIAN’S INFORMATION
Diet Order Form will be returned to parent / guardian and NO accommodations will be
made if this section is not complete.
Medical Authority Signature
Date
X
Medical Authority Printed Name
maní.
This form must be completed at the start of each school year and each time student's
• Esta publicado en: http://www.cms.k12.nc.us/cmsdepartments/cns. No se requiere comdiagnosis or change of treatment is indicated during the school year. Annual
pletar una Autorización de Dieta si la información anterior es suficiente para que el padre /
completion
this form
by the
authority ensures that current
guardiánofmaneje
la dieta
del student's
estudiante medical
en la escuela.
nutritional needs are being met at school.
Medical Office Stamp (Required for processing)
• Esta información debe completarse al principio de cada año escolar y cada vez que cambie
el diagnóstico del estudiante o cambie su tratamiento durante el año escolar. La planilla
PART
C. To be completed by Child Nutrition Services
completada anualmente por la autoridad médica asegura que las necesidades nutricionales
actuales se cumplen en la escuela
PART C. To be completed by Child Nutrition Services
Para ser completado por los Servicios de la Nutrición del Niño
Office Phone Number if not in the stamp
Fax Number
In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race,
Form
# national
DietOrder
| 6/16(male or female), age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication,
color,
origin, gender
1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or
have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).
USDA is an equal opportunity provider and employer.
Created by Child Nutrition Services on 8/17/2015
8
DO NOT WRITE IN THIS AREA
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