Diet Modification

Diet Modification Request Form

Modifications are required by The United States Department of Agriculture (USDA) to accommodate a disability. Under Section 504, the ADA, and Departmental Regulations of 7 CFR part 15b define a person with disability 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. “Major life activities” are broadly defined and include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. “Major life activities” also include operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. This form must be completed by a “medical authority” that is authorized by state law to write medical prescriptions: In Iowa this includes only Medical Doctors (MD), Doctors of Osteopathic Medicine (DO), Physician’s Assistants (PA), or Advanced Registered Nurse Practitioners (ARNP).

Please return completed forms to CCSD Department of Food and Nutrition, Attn: Ginny Scott, 401 76th Ave SW, Cedar Rapids, IA 52404. Email: vscott@crprairie.org

USDA Nondiscrimination Statement

Revised 5-5-22

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

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

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

  1. Mail:
    U.S. Department of Agriculture
    Office of the Assistant Secretary for Civil Rights
    1400 Independence Avenue, SW
    Washington, DC 20250-9410; or
  2. Fax:
    (833) 256-1665 or (202) 690-7442; or
  3. Email:
    program.intake@usda.gov

This institution is an equal opportunity provider.

Declaración de no discriminación del Departmamento de Agricultura (USDA)

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Iowa Nondiscrimination Statement

Revised 3-21-16

It is the policy of this CNP provider not to discriminate on the basis of race, creed, color, sex, sexual orientation, gender identity, national origin, disability, age, or religion in its programs, activities, or employment practices as required by the Iowa Code section 216.6, 216.7, and 216.9. If you have questions or grievances related to compliance with this policy by this CNP Provider, please contact the Iowa Civil Rights Commission, Grimes State Office Building, 400 E 14th St, Des Moines, IA 50319-1004; phone number 515-281-4121 or 800-457-4416; website: https://icrc.iowa.gov/.