PRIORITY NUTRITION CARE DISTANCE DIETETIC INTERNSHIP PRECEPTOR INFORMATION *PLEASE FILL OUT AND SUBM...

PRIORITY NUTRITION CARE DISTANCE DIETETIC INTERNSHIP PRECEPTOR CONFIRMATION*PLEASE FILL OUT AND SUBMIT ONLINE* (approximately 15 min.)

Please see our website www.PNCDDI.com for information under the Preceptors and Rotations tab.

The Accreditation Council for Education in Nutrition and Dietetics (ACEND) of the Academy of Nutrition and Dietetics (AND) defines a "Preceptor" as "a practitioner who serves as faculty for students/interns during supervised practice by overseeing practical experiences, providing one-on-one training, and modeling professional behaviors and values". THANK YOU IN ADVANCE FOR TAKING YOUR TIME TO HELP A FUTURE DIETITIAN. THIS FORM MUST BE SUBMITTED IN ORDER FOR THE CURRENT INTERN OR APPLICANT TO BE ABLE TO REPORT THAT YOU ARE ONE OF HIS/HER PRECEPTORS.
Please complete the following information:
Preceptor First Name*
Preceptor Last Name*
Credentials (RDN, Lic.SW, BS etc.*
Are you an RD/RDN ?*

YesNo
If you are a Registered Dietitian Nutritionist, please provide your registration. If not, please write "N/A".*
If you are credentialed in another profession, please provide your credentials, i.e. degree(s), registration, licensure etc.
Has an Intern or applicant requested that you precept him/her ?*

Current InternApplicant
Is the Intern an employee of your facility ?*

YesNo
Intern Last name*
First Name*
APPLICANT/INTERN EMAIL ADDRESS
example@example.com
Preceptor's preferred contact information
Preferred E-mail*
Preferred telephone*
Is this number (please check)*

HomeWorkCell
Preceptor's primary employer (may be self)*
Name of Organization*
Would the Intern be precepted at this location ?*

YesNo
If No, where will Intern be precepted ?
How long will you be able to Precept the Intern ?*

Full Rotation 6 week, 8 hrs a day/32 hrs a week(Community, Food Service or Clinical)Less than Full RotationFull Rotation 7 weeks, 8 hrs a day/32 hrs a week (Elective Rotation)Less than Full Elective Rotation
If you are unable to Precept the Intern for the full Rotation, how many weeks can you precept ?
In which rotations will you be precepting the applicant ? Please check all that apply.*

Clinical In Person (RDN Only)Food Service In PersonCommunity In PersonElective In Person
THE FOLLOWING QUESTIONS REFER TO THE FACILITY IN WHICH THE INTERN WOULD COMPLETE SUPERVISED PRACTICE

PLEASE NOTE THAT PER US DEPARTMENT OF EDUCATION REGULATIONS AND THE ORGANIZATION OF THE INTERNSHIP CURRICULUM, AN INTERN MAY NOT WORK FROM HOME OR BE GIVEN WORK TO DO AT HOME IN LIEU OF ATTENDANCE AT THE SITE.

DUE TO NUMEROUS STATE AND FEDERAL EMPLOYMENT LAWS, PRIORITY NUTRITION CARE DIETETIC INTERNS MAY NOT BE EMPLOYED AT THE FACILITY THROUGH AT WHCIH THEY ARE COMPLETING A SUPERVISED PRACTICE EXPERIENCE. THANK YOU FOR YOUR UNDERSTANDING.
Name of Facility where Intern will be precepted*
Name of Parent Organization if applicable.
Address Number & Street where Intern will be precepted*
City or Town*
State*
ZIP*
Facility Phone number*
Regardless of whether you agree to act as a Preceptor for a single rotation or part of a rotation, there are specific requirements that must be met to meet the standards of the Internship's accrediting body (ACEND of AND). The following categories will help us match available experiences to requirements and attempt to help the applicant develop a combination of experiences that will help him/her fulfill the competencies required. Thank you in advance for completing this checklist. It should be noted that some of the learning experiences, which are required of all students, can be fulfilled in several different rotations.
In which of the following areas are you personally able to supervise the Intern or oversee experiences related to these areas ?*

Clinical Nutrition Inpatient (RDN Only)Clinical Nutrition Outpatient (RDN Only)Medical Nutrition Therapy (MNT) (RDN Only)Nutrition Focused Physical Exam (RDN Only)Nutrition Care Process (NCP) (RDN Only)Food Service Management InpatientFood Service Management OtherCommunity Nutrition AdultCommunity Nutrition PediatricSchool NutritionSchool Food ServicesCollege/University Food ServicesCollege/University Nutrition ClinicResearchWellnessSports Nutrition (RDN Only)WICRehabilitation ServicesPsychiatric ServicesPrivate Practice (RDN Only)Long Term CareMeals on WheelsElder Services ProgramsHome CareOther
Please add additional comments below if desired.
In which of the following areas would there be opportunities for the Intern to be involved when under your supervision or oversight ? Please check all that apply.*

Endocrine DisordersOverweight & obesityRenal DiseaseCancerGastrointestinalCardiovascularNot Applicable
With which of these groups would the Intern have an opportunity to be involved when under your supervision or oversight ? Please check all that apply.*

InfantsChildrenAdolescentsAdultsPregnant/Lactating WomenElderlyCulturally diverseNone of the above
There are certain Internship accrediting requirements (ACEND) to which all Preceptors must agree in order for the Internship to comply with the accrediting body's (ACEND) requirements.
The following is a statement from the Accreditation Standards for all programs. "The program director, faculty members and preceptors should participate in activities for professional growth and continued competence as dietetics professionals and as educators. Activities can include attendance at national, state or local dietetic association and education meetings; professional development; and academic studies. Resumes are preferred for documenting professional and educational development activities; however, if not available, then narrative summaries describing completed activities are acceptable." If the applicant is matched to our program, we must ask you to provide us with a copy of your Registration, Resume and Outline of recent CE activities.
Please attach your current resume. If you do not have a resume, the following is a link to a fast resume builder tool. https://uptowork.com/
Please upload Resume here:*

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Please upload a brief summary of CEUs here if not included on your resume.

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Please upload Summary of CEUs here:

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OR Briefly list CEU activities here:
If I become a Preceptor for the applicant listed above, I agree: 1.) to provide the Internship with my RDN number if applicable. 2.)to provide the Internship with a list of continuing education activities for the last year. 3.) to to read and be familiar with materials provided by the Internship related to the Intern's experience at the site 4.) that I or my designee will orient the Intern to the facility. 5.) that I and/or my facility will not use Interns to replace employees. 6.) to guide the Intern in scheduling learning experiences, provide daily experiences, and mentor the Intern. 6.) that I will become familiar with the Intern's syllabus 7.) that I will complete Intern evaluations using the forms provided. 7.) that I will be the point of contact for my site for the Priority Nutrition Care DI Program Director or Program Coordinator.*

YesNo
Thank you very very much, on behalf of our program and the applicant, for taking the time to fill out this form.
YOUR SIGNATURE (Please type)*
E-mail*
Telephone*
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Please print a copy of this form for your records before submitting.
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