Brownsville Independent School District

Brownsville Independent School District
Food & Nutrition Service
1900 E. Price Road • Brownsville, TX 78521
Office (956) 548-8450 • Fax (956) 982-2898
Dr. Esperanza Zendejas
Superintendent of Schools
Figure1. Eating and Feeding Evaluation: Children with Special Dietary Needs
PART A
Student's Name:
Name of School:
Grade Level:
Does the Child have a Disability that requires diet/feeding modifications? If yes, please
submit a Diet Prescription form signed by a licensed U. S. physician to the school nurse.
Does the Child have special nutritional or feeding needs? If yes, the diet prescription
must specify exactly what the special needs are.
If the Child is not disabled, does the child have special nutritional or feeding needs? If yes,
a Diet Prescription form signed by a licensed U. S. physician is required.
Age:
Classroom:
Yes
No
Yes
No
Yes
No
If the child does not require special meals, the parent can sign at the bottom of this form and return the form to the district
Food & Nutrition Service Office.
PART B
List dietary restrictions and special diet ordered.
List any food allergies and foods to avoid.
List foods allowed for substitutions and/or feeding supplements.
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 or Blended:
List any special preparation equipment or utensils needed.
Indicate any other comments about the child's eating or feeding patterns.
Parents Signature
Date:
Physician / Physician Asst. / Nurse Practitioner Signature
Date:
The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender
identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public
assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or
employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html,
or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to
us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
program.intake@usda.gov.
BISD does not discriminate on the basis of race, color, national origin, sex, religion, age, disability or genetic information in employment or provision of services, programs or activities.
BISD no discrimina a base de raza, color, origen nacional, sexo, religión, edad, discapacidad o información genética en el empleo o en la provisión de servicios, programas o actividades.
Brownsville Independent School District
Servicios de Alimentación y Nutrición
1900 E. Price Road • Brownsville, TX 78521
Office (956) 548-8450 • Fax (956) 982-2898
Dr. Esperanza Zendejas
Superintendent of Schools
Figura 1. Evaluación sobre Comer y Alimentar: niños con necesidades dietéticas especiales
Nombre del Estudiante:
PARTE A
Nombre del a Escuela:
Grado Escolar:
Edad:
Salón:
¿Tiene el niño alguna discapacidad que requiera modificaciones en su
Sí
No
dieta/alimentación? Si es un si, favor de enviar la forma de Prescripción de la Dieta,
firmada por un médico con licencia de EE.UU a la enfermera escolar.
¿Tiene el niño alguna necesidad nutricional o de alimentación especial? Si es un Si, la
Sí
No
prescripción de la dieta debe especificar exactamente que necesidades especiales son.
Si el niño no está discapacitado, ¿tiene el niño alguna necesidad de nutrición o de
No
alimentación especial? Si es un Si, se requiere la forma de Prescripción de la Dieta, firmada Sí
por un médico con licencia de EE.UU.
Si el niño no requiere de comidas especiales, el padre puede firmar en la parte baja de esta forma y regresarla a las oficinas
de Servicios de Alimentación y Nutrición
PARTE B
Lista de restricciones en la dieta y ordenes de dieta especial.
Lista de cualquier alergia alimenticia y alimentos que debe evitar.
Lista de alimentos permitidos para sustituciones o suplementos de la alimentación.
Lista de los alimentos que necesitan el siguiente cambio en la textura. Si todos los alimentos tienen que ser preparados de
esta manera, indicar "Todo".
Desmenuzado o picado en trozos pequeños:
Finamente molido:
Hecho puré o mezclado:
Lista de cualquier equipo especial de preparación o utensilios necesarios.
Indique algunas observaciones sobre patrones en el comer o de alimentación de su niño.
Firmas de los Padres
Fecha:
Firma del Medico/Asistente de Medico/Enfermera Practicante
Fecha:
The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender
identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public
assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or
employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html,
or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to
us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
program.intake@usda.gov.
BISD does not discriminate on the basis of race, color, national origin, sex, religion, age, disability or genetic information in employment or provision of services, programs or activities.
BISD no discrimina a base de raza, color, origen nacional, sexo, religión, edad, discapacidad o información genética en el empleo o en la provisión de servicios, programas o actividades.