Supervised Practice Facility Information Form

Which rotations will be accomplished at this facility (check all that apply):

Medical Dietetics

Clinical InpatientLong Term CareOutpatientCritical CareStaff ReliefNot Applicable

Specific disease processes:

Option 1DiabetesCancerCVDSGI DiseaseRenalNot Applicable

Food Service Management

SchoolAcute CareLong-Term CareRehabOtherNot Applicable

Please Define

Community

WICHead StartPublic HealthWellnessSchoolLong Term CareOtherNot Applicable

Text

Intern Assigned to this Facility

First Name

Last Name

Brief description of facility/agency/institution (mission, population served, etc)

Number of Registered Dietitian Nutritionists employed full-time

Number of Registered Dietitian Nutritionists employed part-time

Number with advanced degree and/or specialized certification

Number of Nutrition and Dietetic Technician Registered (NDTR) employed full-time

Number of Nutrition and Dietetic Technician Registered (NDTR) employed part-time

Typical Inpatient/client Census

Weekly Outpatient Census

Dietetics