UTAH STATE UNIVERSITY PRECEPTOR & FACILITY INFORMATION FORM

UTAH STATE UNIVERSITY PRECEPTOR & FACILITY INFORMATION FORM

This information on this form will be used collect information about preceptor and facility requirements for the purpose of ACEND accreditation. Please contact us if you have any questions.
Student Name:
Please include the name of the student you plan to work with
Preceptor Name:
Professional Credentials (including highest degree attained):
e.g. MPH, RDN, CSSD
Preceptor Email:
example@example.com
Preceptor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Job Title:
Facility or Organization Name
Address of Facility
City, State, Zip Code of Facility
Facility Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years preceptor has worked for this facility:
Average number of hours that preceptor works per week
Have you precepted students in the past?
Total number of dietitians at the facility (include FT and PT positions):
Facility Type

Other
If answered "Other" to Facility Type, please describe facility in text box.
For inpatient or long-term care facilities only, please include the number of beds:
Will students be able to train in an ICU setting?
Will students gain experience with nutrition support?
Are you the appropriate contact to set up a legal agreement between USU and this facility?
If no, please provide the name of the person we can contact to set up a legal agreement between USU and facility?
Contact information for the legal agreement (phone and email):
Please attach a current resume, CV, or PDP log for the preceptor. It is okay if the current copy has not been updated recently. If you are having any issues uploading your resume, CV or PDP log, please email the USU MDA at usumda@usu.edu

Cancelof
Preceptor Expectations:

Preceptors for the USU Master of Dietetics Administration are expected to fulfill the following:
- Provide students with an orientation to the facility, daily schedule, and required facility information
- Guide and mentor students according to your knowledge, skills, and abilities
- Provide students with opportunities to put knowledge into practice and strengthen problem solving skills
- Help students identify information essential to their future role as dietitians
- Provide regular constructive feedback throughout the rotation
- Evaluate students' performance through a final evaluation at the conclusion of the rotation.
I have read and understand the expectations of preceptors for the USU Masters of Dietetics Administration.
Please verify that you are human
Should be Empty: