Supervised Practice Facility Information Form If you are human, leave this field blank.Supervised Practice Facility Information FormPlease note: Only one facility form is needed per facility.Date *Facility Name *Address *Address 2 *City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Zip +4 *Name of Department HeadPreceptor First Name *Preceptor Last Name *Email *Person filling out form (contact)Contact Name *Contact Title *Contact Phone Number *Contact Email *Facility FAX Number *RotationsWhich rotations will be accomplished at this facility (check all that apply):Medical Dietetics *Clinical InpatientLong Term CareOutpatientCritical CareStaff ReliefNot ApplicableSpecific disease processes: *Option 1DiabetesCancerCVDSGI DiseaseRenalNot ApplicableFood Service Management *SchoolAcute CareLong-Term CareRehabOtherNot ApplicablePlease Define *Community *WICHead StartPublic HealthWellnessSchoolLong Term CareOtherNot ApplicableText *Intern Assigned to this FacilityIntern First Name *Intern Last Name *Intern Email *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 *If this practice site/facility will provide a foodservice systems management experience for the intern please answer the following:Name of Foodservice DirectorFood Service Director First Name *Food Service Director Last Name *Basic type of operation (e.g. cook-chill, conventional, room service etc.) *Number of employees FTE’s *Total Number of patrons served per day *Submit
