Preceptor Information Form

Preceptor Information Form

• 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

Verification of Review

1. I verify that I have reviewed the Marshall University Dietetic Internship website:

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.


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