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

PRIORITY NUTRITION CARE DISTANCE DIETETIC INTERNSHIP PRECEPTOR INFORMATION *PLEASE FILL OUT AND SUBMIT ONLINE*

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.

You have been asked to complete this form because a current or potentially future Priority Nutrition Care Distance Dietetic Internship intern has indicated that you are willing to act in the capacity of Preceptor for him or her. One of the requirements of our program is that the interns arrange for their own preceptors, usually close to home. The only way to ascertain whether a Preceptor has agreed to work with an Intern for us to hear it from the Preceptor. The rotations in which Preceptors are required include Clinical Nutrition, Food Service Management, Community, and an Elective rotation. There could be more than one location/site involved in any of these 4 major areas and/or one individual may precept in more than one rotation type. All preceptors DO NOT have to be Registered Dietitians. However, the student must have RD/RDNs in their Clinical rotations specifically to supervise the Nutrition Care Process and MNT. An RD who is willing to assist the student in locating different sites and/or experiences and guide the Intern in a situation where a preceptor may be in another profession (s.a. RN, Nurse Practitioner, Social Worker, Psychologist etc.) may be designated as a Primary Preceptor for the Intern and assist them through what can be a daunting challenge in locating other practice sites and learning experiences. The experience and local contacts of the Primary Preceptor would be of great benefit to a student seeking to become a Registered Dietitian. ACEND has recently given DI Programs more latitude in placing students and no longer mandates certain experiences and locations. Instead, we can be more creative in finding ways that Interns can meet the required competencies.

Please complete the following information:

Preceptor Last Name

First Name

Credentials

Are you an RD/RDN ? *

Yes No

If YES, what is your registration number?

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 Intern Applicant

Intern Last name

First Name

Is the Intern or applicant your employee ?

Yes No

Preceptor's preferred contact information

Is this ?

work home

Number & Street

City or Town

State

Zip

Preferred E-mail

Preferred telephone

Is this number (please check)

Home Work Cell

Preceptor's primary employer (may be self)

Would the Intern be precepted at this location ?

Yes No

Employer address (number & street)

City or Town

State

Zip

Additional employer

Would the Intern be precepted at this location ?

Yes No

Address (number and street)

City or Town

State

Zip

THE FOLLOWING QUESTIONS REFER TO THE LEVEL OF INVOLVMENT YOU ARE WILLING TO HAVE WITH THE APPLICANT AS HIS/HER PRECEPTOR

A Primary Preceptor would precept the Intern in one or more areas and use his/her contacts to work with the applicant and the Internship Program to locate appropriate experiences and sites or help the Intern fill in gaps in the supervised practice plan by suggesting contacts.

Would you be willing to act as a Primary Preceptor for the applicant ?

Yes No

Please note: Clinical Nutrition Rotations (Inpatient facilities are preferred but may be in or out patient in many potential settings,which may include, but is not limited to hospitals, nursing homes, extended care facilities with rehab units, clinics, dialysis centers, radiation therapy departments, private medical offices (must be full time offices) of RD/RDNs, CDEs etc.) Food Service Rotations (May be in Health Care Facilities of any kind, public school systems, colleges & universities, businesses, retail, supermarkets, restaurants.) Community Nutrition Rotations (May be in a public health or community program of any kind, home care, supermarkets,schools, colleges and universities, extension programs,WIC, Meals on Wheels, Elderly congregate dining.) Elective Rotations During the elective rotation,during which the Intern may return to a previous site or go to a new site, the Intern is expected to complete two projects related to the concentration area he/she has chosen, which may be either the Business of Nutrition or The Management of Food and Nutrition Services. These projects may have been started in previous rotations.

If you answered Yes above, in which rotations are you able to personally supervise the applicant OR use your contacts to help the applicant arrange the necessary experiences. Please check all that apply.

Clinical Food Service Community Elective

Please note: Interns may be required to complete experiences at more than one site during one rotation. (example: An Intern is required to be exposed to renal patients but the experience would not comprise an entire 8 week clinical rotation).Certain experiences which may have been viewed in the past as fitting a particular category may now be considered in more than one (ex. MNT may occur in Clinical or Community). Both FS and Community may be completed in public school systems.)

Please check all areas in which you would be able to personally precept an Intern.

Clinical Community Food Service Elective

THE FOLLOWING QUESTIONS REFER TO THE FACILITY IN WHICH THE INTERN WOULD WORK

While a student may locate a Preceptor, the Preceptor must be able to affirm that the administration of the site where the supervised practice will take place will be willing to enter into an affiliation agreement with the Priority Nutrition Care LLC, using the facility's own affiliation agreements/contracts or those of Priority Nutrition Care LLC. These agreements are usually very similar in content.

Per accrediting body requirements, affiliation agreements must be signed for any experience in which the Intern will spend more than one week and/or for any experience of any length in which the Intern will be providing direct patient/client care. PNCDDI Affiliation agreements will not be initiated until the Preceptor has agreed to work with the student and THE STUDENT HAS BEEN MATCHED TO THE PROGRAM. PNCDDI is willing to enter into agreements using either their own agreement or that of the host facility. PNCDDI generated agreements may be transmitted and signed electronically.

Does the facility(ies) in which you plan to precept the Intern require its own affiliation agreement/contract be used or that of the Internship Program ?

Facility generated agreement Internship generated agreement

If the facility requires an Internship generated agreement, please fill in the information below which will be included on the affiliation agreement/contract. Please note that is is only a rare instance in which the preceptor would be viewed as a "duly authorized signer" on behalf of an institution or facility, unless the preceptor is the owner or officer of the business.

Name of Facility where Intern will be precepted

Address Number & Street where Intern will be precepted

City or Town

State

ZIP

Facility Phone number

Please complete the following if the information required on the affiliation agreement/contract is different from the name of the local facility (i.e. the local facility is a part of a large company).

Legal Name of Facility/ Parent Company/ Municipality etc. as it should appear on contract

Address Number & Street

City or Town

State

Zip

Contact phone number

Duly Authorized Signer on behalf of the facility/Facility Contract/Business Officer/Signer (i.e. Person who will sign the affiliation agreement)

Title of Signer

All of the PNCDDI Interns will be required to submit to a background check which will include criminal background and providing medical clearance, including drug screen, documentation of immunizations, and criminal information including nationwide SORI. They will also be required to agree to provide all information requested by the host facility, which may also include fingerprinting. At this time, are you aware of any specific requirements of your facility for Interns in these areas ? Knowing this in advance helps to expedite the process of retrieving the information. Please specify below.

Regardless of whether you agree to act as a Preceptor for a single rotation, part of a rotation, or a Primary Preceptor who may personally supervise or oversee an Intern who is under the direct supervision of another professional, 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. Be assured that the Intern will arrive with (and you will receive in advance of the Rotation), a detailed list of learning experiences, which would be typically involved in each Rotation. While these experiences are detailed, they provide enough flexibility for you to be able to assign the Intern activities and projects which should be useful at your facility.

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.

Endocrine Disorders Overweight & obesity Renal Disease Cancer Gastrointestinal Cardiovascular

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.

Infants Children Adolescents Adults Pregnant/Lactating Women Elderly Culturally diverse

There are certain requirements to which all Preceptors must agree in order for the Internship to comply with the accrediting body"s (ACEND) requirements. Please respond to the following:

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/

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." As such, we must ask you to either attach (see select file below) a print out of your CDR or Licensure submission with names and approximate dates of attendance for the last year OR fill in the box below as a narrative with the same information.

OR List professional activities here.

If I become a Preceptor for the applicant listed above, I agree: 1.) to provide the Internship with a copy of my professional credentials. (If an RD from CDR, if an RN from the state board of licensure etc.) 2.)to provide the Internship with a list of completed continuing education activities for the last year. 3.) to to read and be familiar with materials related to the Intern's experience at the site provided by the Internship 4.) that I or my designee will adequately 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 complete Intern evaluations (including both written and oral work) using the forms provided. 7.) that I will become familiar with and abide by the PNCDDI handbook including policies and procedures. 8.) that I will be the point of contact for the PNCDDI Program Director or Program Coordinator.

Yes No

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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