Preceptor Confirmation Form

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 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 INTERN TO BE ABLE TO REPORT THAT YOU ARE ONE OF THEIR PRECEPTORS.

PRIORITY NUTRITION CARE IS AVAILABLE TO ANSWER ANY QUESTIONS YOU MAY HAVE AT ANY TIME. PLEASE EMAIL US AT INTERNSHIP@PRIORITYNUTRITIONCARE.COM.

This form asks for specific information related to the contractual/affiliation agreement information needed to enter into an agreement. You will need this information in order to complete the form.

This information includes:
Legal name of the controlling Organization
Corporate Address of Organization
Telephone and email contact information of the Administrator/Legally designated signer.

Please note that the legally designated signer is someone who has the authority to bind the origanization legally. Preceptors may not sign contracts unless they have been designated to do so by their organization and can provide documentation confirming that.

Priority Nutrition Care LLC has a contract template which we can originate. However, many organizations prefer to initiate their own contracts and Priority Nutrition Care will work with the Organization to complete those contracts.

We are unable to contract with an organization who is a subcontractor for that organization. We can however, contract directly with the facility.

Private Practices Owned and Operated by RDNs may be used during the elective rotation only, as long as the business maintains a physical business office (not a home office), has a business website, employs more than one full time equivalent RDN, has a robust client panel and/or consulting clientele, the business meets Federal, State and Local business Requirements and can provide a Certificate of Insurance for Professional and General Liability and has a secure HIPPA compliant medical record platform in place.

Please complete the following information:

(RDN required for clinical rotation only)

Preceptor Last Name

Preceptor First Name

Credentials Ex. (RDN, BS etc.)

Are you an RD/RDN ?

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.

Preceptor's Preferred E-mail

Preferred telephone

Is this number (please check)

Preceptor's primary employer

Is the Intern an employee of your facility ?

Intern Last name

First Name

INTERN EMAIL ADDRESS

example@example.com

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, AS WELL AS CONTRACTUAL OBLIGATIONS, PRIORITY NUTRITION CARE DIETETIC INTERNS MAY NOT BE EMPLOYED AT THE FACILITY AT WHICH THEY ARE COMPLETING A SUPERVISED PRACTICE EXPERIENCE. THANK YOU FOR YOUR UNDERSTANDING.

Organization will use their own contract

Legal Name of Parent Organization

Name of Site at which Intern will be precepted

Number & Street of Site at which Intern will be precepted

City, State & Zip of Site at which Intern will be precepted

Name of individual who will be handling the contract

Name, email address and phone number of individual who will be handling the contract process

Last name

First Name

If you responded YES previous question, please see our contact information below and provide it to the person who will be administering the contract on behalf of your organization:

Legal Name - Priority Nutrition Care LLC

Address - PO Box 148 Hingham, MA 02043

Legal Signer -Anne Manion MBA, RD

Signer Title - Chief Executive Officer

Organization will use Priority Nutrition Care LLC contract

Legal name of Parent Organization

Address Number & Street , City, State and Zip code of Parent Organization

Name of Facility where Intern will be precepted

Address Number & Street, City, State & Zip Code of faciltiy where Intern will be precepted

City or Town

State

ZIP

Facility Phone number

INTERNS may be either FULL TIME or PART TIME

FULL TIME = 4 days/wk Mon-Thurs - 8 hrs/day - 6 wks on site

PART TIME = 2 days/wk between Monday & Thursday-8 hrs/day 9 wks on site

INTERNS are engaged with INTERNSHIP administration and staff all day on FRIDAYS for the duration of the INTERNSHIP. They do not go to sites on Fridays.

I am able to precept the INTERN:

In which rotation will you be precepting the intern?

Regardless of whether you agree to act as a Preceptor for a single rotation or more, 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 them 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 ?

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.

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.

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:

Browse Files

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

Browse Files

Please upload Summary of CEUs here:

Browse Files

OR Briefly list CEU activities here:

If I become a Preceptor for the Intern 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 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. 7.) that I will become familiar with the Intern's syllabus 8.) that I will complete Intern evaluations using the forms provided. 9.) that I will be the point of contact for my site for the Priority Nutrition Care DI Program Director or Program Coordinator.

If I become a Preceptor for the Intern 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 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.

7.) that I will become familiar with the Intern's syllabus

8.) that I will complete Intern evaluations using the forms provided.

9.) that I will be the point of contact for my site for the Priority Nutrition Care DI Program Director or Program Coordinator.

I agree to the previous statements.

Thank you very very much, on behalf of our program and the Intern or applicant, for taking the time to fill out this form.

YOUR SIGNATURE (Please type)

Signature

E-mail

Telephone

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Please print a copy of this form for your records before submitting.