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.
Job Title: *
Facility or Organization Name *
Address of Facility*
City, State, Zip Code of Facility *
Facility Phone Number *
Please enter a valid phone number.
Years preceptor has worked for this facility:*
Average number of hours that preceptor works per week*
Have you precepted students in the past?*

YesNo
Total number of dietitians at the facility (include FT and PT positions):*
Facility Type*

Clinical Inpatient (8 - 10 wks)Clinical Outpatient (3 wks)Long-term Care (2 wks)WIC (1 -4 wks)Community (1 -4 wks)School Food Service Management (8 wks)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?

YesNoNot applicable
Will students gain experience with nutrition support?

YesNoNot Applicable
Are you the appropriate contact to set up a legal agreement between USU and this facility?*

YesNo
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 or CV for preceptor*

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 informaion 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.*

YesNo
Please verify that you are human*
Should be Empty: