Current Intern Rotation Schedule

ROTATION & PRECEPTOR INFORMATION SCHEDULE

EVERY TIME YOU MAKE A CHANGE IN A PRECEPTOR OR ROTATION YOU MUST SUBMIT THIS FORM.

Please note: If you are adding, deleting or changing information please describe the change(s) you have made in the box below AND make the changes further down on the form itself.

PLEASE READ THIS ENTIRE FORM BEFORE YOU START

Please complete this form about your preceptors and planned schedule for whichever preceptors and rotations you have identified to date.

You will receive an email at the email address you provide below with a copy of this form. It will have an EDIT button in the upper left which will allow you to EDIT this form. PLEASE SAVE THAT EMAIL. We do not have access to that link. If you do not have it, you will need to complete the form again in full.

Class starting:

YOUR Name*

Last NameFirst Name

YOUR E-mail*

I have applied for and received PAL credit?*

YESNO

I have made a change(s) to my schedule.*

YESNO

What changes have you made ? Check all that apply.*

To which Rotation(s) have you made additions, deletions or changes. Check all that apply*

Please describe edits/changes made to your previous rotation schedule and why? Please be very specific. If this is a first submission, please say so.Please include Rotation numbers, names of facilities, preceptors etc.

Today's Date*

MonthDayYear

YOUR CELL*

Area CodePhone Number

Address during Internship*

Street Address

Street Address Line 2

CityState

Zip Code

YOU MAY CHOOSE ONE SITE PER ROTATION. PLEASE COMPLETE THE FOLLOWING INFORMATION ABOUT YOUR SITES AND PRECEPTORS.

PLEASE NOTE:

ALL Rotation Sites must be IN PERSON. Please see our website for more information on rotation sites. ALL sites and preceptors must be vetted and approved by the Internship.

CLINICAL ROTATION

PRECEPTOR MUST BE AN RDN FOR THE ENTIRE ROTATION.
MAY BE INPATIENT OR OUTPATIENT.
MAY BE A DIALYSIS UNIT

COMMUNITY ROTATION

IF YOU HAVE WORKED AT WIC PREVIOUSLY, YOU MAY WANT TO APPLY FOR PAL CREDIT for COMMUNITY.
COMMUNITY ROTATIONS MUST INVOLVE WORKING FACE TO FACE WITH THE COMMUNITY.

FOOD SERVICE ROTATION

IF IN A SCHOOL SYSTEM, IT MUST BE A PUBLIC SCHOOL "SYSTEM".

ALL ROTATIONS

ALL PRECEPTORS MUST BE A EMPLOYEE VIA SITE THEY WILL BE PRECEPTING YOU. THEY MAY NOT BE A CONTRACTED EMPLOYEE.

THE FOLLOWING SITES WILL NOT BE APPROVED:

Private MD Practices

**Private RDN Practices

Gym/Personal Training businesses

Psychiatric Programs

Substance Abuse Programs

Sites which run their own Dietetic Internships

Remote sites - You may not work from home

Hybrid Arrangements

**Private Practice Preceptor must provide documentation reagrding the list below: (This is all related to liability - for PNC and the Intern-, licensure, and having a practice that is robust enough to provide a quality experience for the Intern, among other things.)

Must be a Registered Dietitian
Have a physical office space in which they see clients/patients (Monday through Friday) where the Intern will be on all of their rotation days (Interns may not travel to other sites - again due to liability issues)
Have maintained or been employed by a full time private practice for a minimum of 5 years
The practice must be registered as a business within their state
See clients/ patients in person in their office at least 80% of the time
Provide Priority Nutrition Care with a Certificate of Insurance which includes both Professional and General Liability
Maintain a secure Medical Record System which is HIPAA compliant.
Maintain Licensure in any state in which they conduct telemedicine from their office
The Preceptor's practice must be related to nutrition and dietetics 100% of the time (i.e. not in combination with physical training for example)

Rotation 1: TYPE OF ROTATION

Name of Facility

City/State

Street Address

Street Address Line 2

CityState

PRECEPTOR'S LAST NAME

Last Name

PRECEPTOR'S FIRST NAME

First Name

PRECEPTOR'S CREDENTIALS

Credentials (i.e. RDN, BS, CDM etc.)

PRECEPTOR'S EMAIL

example@example.com

PRECEPTOR'S Phone Number

Area CodePhone Number

Have you received a firm commitment from this preceptor?

YesNo

Please describe the type of facility in detail and what you will be doing there.

Rotation 2: TYPE OF ROTATION

Name of Facility

City/State

Street Address

Street Address Line 2

CityState

PRECEPTOR'S LAST NAME

Last Name

PRECEPTOR'S FIRST NAME

First Name

PRECEPTOR'S CREDENTIALS

Credentials (i.e. RDN etc.)

PRECEPTOR'S EMAIL

example@example.com

PRECEPTOR'S Phone Number

Area CodePhone Number

Have you received a firm commitment from this preceptor?

YesNo

Please describe the type of facility in detail and what you will be doing there.

Rotation 3: TYPE OF ROTATION

Name of Facility

City/State

Street Address

Street Address Line 2

CityState

PRECEPTOR'S LAST NAME

Last Name

PRECEPTOR'S FIRST NAME

First Name

PRECEPTOR'S CREDENTIALS

Credentials (i.e. RDN etc.)

PRECEPTOR'S EMAIL

example@example.com

PRECEPTOR'S Phone Number

Area CodePhone Number

Have you received a firm commitment from this preceptor?

YesNo

Please describe the type of facility in detail and what you will be doing there.

Rotation 4: TYPE OF ROTATION

Name of Facility

City/State

Street Address

Street Address Line 2

CityState

PRECEPTOR'S LAST NAME

Last Name

PRECEPTOR'S FIRST NAME

First Name

PRECEPTOR'S CREDENTIALS

Credentials (i.e. RDN etc.)

PRECEPTOR'S EMAIL

example@example.com

PRECEPTOR'S Phone Number

Area CodePhone Number

Have you received a firm commitment from this preceptor?

YesNo

Please describe the type of facility in detail and what you will be doing there.

NOTES TO INTERNSHIP

PLEASE PRINT BEFORE SUBMITTING FORM

Type a question

Please consult Rotation Calendar on PNCDDI.com.

ROTATION 1

ROTATION 2

ROTATION 3

ROTATION 4 - 7 WEEKS