Preceptor Information Form If you are human, leave this field blank.Preceptor Information FormPlease choose which option best applies to the preceptor filling out the form *I am a preceptor working with an applicant who is applying to the Marshall University Dietetic InternshipI am an ongoing preceptor working with the Marshall University Dietetic InternshipI am a Preceptor who is interested in working with the Marshall University Dietetic InternshipDate *Dietetic Intern Applicant’s Name (if known)Intern First Name *Intern Last Name *Intern Email *Preceptor InformationPreceptor First Name *Preceptor Last Name *Preceptor Email *Position Title *Credentials *Phone Number *Extension *have a current CDR Registration ID Number *YesNoWhat is the highest level of education you have *Some High SchoolHigh School/GEDSome CollegeAssociate\'s DegreeBachelor\'s DegreeMaster\'s DegreeDoctoral DegreeProfessional DegreeFacility (Where you work now) *City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIs there an Affiliation Agreement in place for your facility *YesNoUnknownEmployeed *Full-timePart-timeIf part-time, is there another (or several other) preceptor(s) that will be available to in mentoring the intern when you are not working? *YesNoNumber of years of experience post credentialing (if applicable) *1 Year1-5 Years6-10 years>10 YearsDo you have prior experience precepting a dietetic intern? *YesNoHave you previously served as a preceptor for a Marshall University Dietetic Intern? *YesNoPRECEPTOR RESPONSIBILITIES• Working with the intern to schedule learning experiences during the rotation • Assisting in orienting the intern to the facility and rotation, and evaluating oral presentations (note these duties can also be delegated to other preceptors/staff at the facility) • Evaluating intern using form provided • Being familiar with and abiding by the Marshall University Dietetics Internship policies and procedures • Acting as the point of contact in the facility for the Marshall University Internship Coordinator and Instructors • Mentoring and providing daily supervised learning experiences for intern My name, credentials, and facility may be posted on the Dietetics Internship website for applicant review. *YesNoVerification of ReviewClicking submit indicates that:1. I verify that I have reviewed the Marshall University Dietetic Internship website: www.marshall.edu/dietetics 2. I have read and understand the Preceptor responsibilities and I am willing to serve in this capacity. 3. If the applicant is selected for the Marshall University Dietetic Internship, I will fulfill the expectations of serving as a preceptor for the intern listed at the top of this form. 4. I agree that the purpose of the supervised practice is for the education and I will not use interns to replace employees. 5. I understand that the purposed of the affiliation agreement is to protect the intern, client/patient/customer, preceptor, facility, and Marshall University. In the event no agreement is entered into by the parties, each party in the shadow/observation-only experience will be responsible for the liabilities arising out of their own conduct and the conduct of their officers, employees and agents. Submit Please print a copy for your records before clicking submit. Affiliate Agreement Process After interns are selected in late April, the Marshall University DDI Program will send the Primary Preceptor of each practice site/facility a “Marshall University Affiliation Agreement.” While most agreements are not signed until a student has been offered and accepted an appointment, practice site/facility administrators should be aware of the content of this essential document early in the application process. After a student accepts an internship appointment, appropriate practice sit/facility administrators will be asked to sign this agreement with Marshall University by July 1st as a condition of the student’s final acceptance into the internship. If you have questions, please contact email@example.com.