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Supervised Practice Facility Information Form

Please note: Only one facility form is needed per facility.

Date *

Facility Name *

Address *

Address 2 *

City *

State *

Zip Code *

Zip +4 *

Name of Department Head

Preceptor First Name *

Preceptor Last Name *

Email *

Person filling out form (contact)

Contact Name *

Contact Title *

Contact Phone Number *

Contact Email *

Facility FAX Number *

Rotations

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

Please Define *

Text *

Intern Assigned to this Facility

Intern 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 Director

Food 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 *