Dietetic Internship Computer Application System (DICAS)
Application Practice Template 2020-2021
Biographical Data
Title
First name
Last name
Middle name
Contact Information
Contact Address
Street
Street2
City
State/Province
Country/Territory
MS
Haiyan
Huang
N/A
2808 Megan St
N/A
Denton
Taxes
Unite State
Suffix
Email address
hhuang1@twu.edu
User name
Permanent Address
Street
Street2
City
State/Province
Country/Territory
N/A
N/A
2808 Megan St
N/A
Denton
Taxes
Unite State
Phone and email
Home phone
N/A
Work phone
N/A
Cell phone
978-9301924
Preferred phone
978-9301924
Phone # to be reached on DICAS match day
Fax
N/A
Primary email address hhuang1@twu.edu
Secondary email address haiyanhuang90@gmail.com
Personal Information
Citizenship
China
Citizenship status
US Permanent Resident
Country of citizenship
Unite State
Hold a Visa? Yes/No; if no, skip next 6 items
No
Visa issue date
Visa type
Visa #
City of Visa
Visa current?
Vita Permit Work
Veteran? Yes/No
No
Background Information
Has disciplinary action, in writing of any sort, ever
been taken against you? Yes/No
If yes, elaborate:
Are there any complaints pending against you? Yes/No
If yes, elaborate:
1
General
Language
Proficiency Level
Materials alias
Alias first name
Alias last name
Nickname
No
No
Female
Chinese
Native Speaker
N/A
N/A
N/A
N/A
Has there ever been a decision in a civil suit rendered
against you? Yes/No
If yes, elaborate:
Have you ever been put on probation, suspended,
terminated or asked to resign? Yes/No
If yes, elaborate:
Have you ever reneged on a DICAS internship match
without prior approval from DICAS and the internship
site?
Have you ever been convicted of a crime? Yes/No
If yes, elaborate
Have you ever been convicted of a felony? Yes/No
If yes, elaborate:
No
No
No
No
No
College(s) Attended
College #1 – name:
UG or GR
Attendance dates (mo./yr. – start and end):
Degree:
Major:
Degree Status:
Date earned/anticipated:
Second major or minor:
Overall cumulative GPA (do not round):
North Central Texas College
UG
August 2017
Associate of Science
General Studies
Incomplete
July 2019
N/A
3.538
College #2 – name:
UG or GR
Attendance dates (mo./yr. – start and end):
Degree:
Major:
Degree Status:
Date earned/anticipated:
Second major or minor:
Overall cumulative GPA (do not round):
Texas Woman’s Universty
UG
August 2018
Bachelor of Science
Nutrition
In progress
May 2022
N/A
3.545
College #3 – name:
UG or GR
Attendance dates (mo./yr. – start and end):
Degree:
Major:
Degree Status:
Date earned/anticipated:
Second major or minor:
Overall cumulative GPA (do not round):
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
College #4 – name:
UG or GR
Attendance dates (mo./yr. – start and end):
Degree:
N/A
N/A
N/A
N/A
2
Major:
N/A
Degree Status:
N/A
Date earned/anticipated:
N/A
Second major or minor:
N/A
Overall cumulative GPA (do not round):
N/A
Coursework
Completed Academic Coursework (copy and paste the next set of rows as needed)
State/Name of College/University: North Central Texas College / Texas Woman’s University
Session Information: Year/Semester/Class – freshman, sophomore, junior, senior
Course
Subject:
Type
Credit
Actual
Numeric Classification
#/name
DPD Sci or
Lecture
Hours
Grade
Grade
DPD Prof
Or
(see
Lecture
attached)
& Lab
NCTC
Courses
NFS 2323
DPD Prof
Lecture 3
A
Freshman
PSY 1013
DPD Prof
Lecture 3
B
Freshman
MATH 1703 DPD Prof
Lecture 3
A
Sophomore
No
No
No
TWU
Courses
CHEM 1013
CHEM 1011
BUS 3003
NFS 2011
NFS 3033
BIOL 1111
BIOL 1113
NFS 1302
NFS 3173
NFS 1301
BACT 1001
BACT 1003
CHEM 1021
CHEM 1023
NFS 3101
NFS 3043
NFS 3083
ZOOL 2011
ZOOL 2013
NFS 3321
NFS 3323
NFS 3713
NFS 3722
ZOOL 2021
ZOOL 2023
SPCH 1013
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
DPD Sci
DPD Sci
DPD Prof
DPD Prof
DPD Prof
DPD Sci
DPD Sci
DPD Prof
DPD Prof
DPD Prof
DPD Sci
DPD Sci
DPD Sci
DPD Sci
DPD Prof
DPD Prof
DPD Sci
DPD Sci
DPD Sci
DPD Prof
DPD Prof
DPD Prof
DPD Prof
DPD Sci
DPD Sci
DPD Prof
Lecture
Lab
Lecture
Lecture
Lecture
Lab
Lecture
Lecture
Lecture
Lab
Lab
Lecture
Lab
Lecture
Lab
Lecture
Lecture
Lab
Lecture
Lab
Lecture
Lecture
Lab
Lab
Lecture
Lecture
3
1
3
1
3
1
3
2
3
1
1
3
1
3
1
3
3
1
3
1
3
3
2
1
3
3
B
C
A
B
A
C
B
B
A
B
B
A
A
B
A
A
B
A
A
B
B
B
A
A
A
A
3
Sophomore
Sophomore
Sophomore
Sophomore
Sophomore
Sophomore
Sophomore
Sophomore
Sophomore
Sophomore
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Junior
Repeated?
NFS 3201
NFS 4301
NFS 4601
NFS 4744
NFS 4303
NFS 4313
DPD Prof
DPD Prof
DPD Prof
DPD Prof
DPD Prof
DPD Prof
Lecture
Lecture
Lecture
Lecture
Lecture
Lecture
1
1
1
4
3
3
A
A
A
A
A
B
Senior
Senior
Senior
Senior
Senior
Senior
No
No
No
No
No
No
Planned/In Progress Academic Coursework (this should match the Declaration of Intent information)
State/Name of College/University: Texas Woman’s University
Session Information: Year/Semester/Class – freshman, sophomore, junior, senior
Course
Subject:
Type
Credit Hours
Classification
Repeated?
#/name
DPD Sci or
Lecture
DPD Prof
Or
Lecture & Lab
NFS 4103
DPD Prof
Lecture
3
Senior
No
NFS 4701
DPD Prof
Lecture
1
Senior
No
NFS 4113
DPD Prof
Lecture
3
Senior
No
NFS 4473
DPD Prof
Lecture
3
Senior
No
Tests
GRE: N/A
Status: N/A
Date: N/A
Verbal: N/A
Verbal %: N/A
Quantitative: N/A
Quantitative %: N/A
Analytical Writing: N/A
Analytical Writing %: N/A
Summary of Dietetic Program Director
DPD Contact Information
First Name: Dolores
Last Name: Kearney
Email address: dkearney1@twu.edu
Document: Declaration of Intent OR Verification Statement
Declaration of Intent, Verified on: DICAS will send this info to you
in an email message
Declaration of Intent, Confirmed: You will do this step via DICAS
College/University of Didactic:
Degree to be Granted:
4
TOEFL: N/A
Verification Statement
Month/Year Degree Completed:
College/University Conferring Degree:
Course(s) and Date(s) of projected completion (list below)
Course #/Course Title/Date to be completed by
Awards, Experience & Volunteer Activities
Honors and Awards (copy and paste next two rows as
needed)
Organization/Award Name: DEAN'S LIST
Date: 2020 SPRING
Description of award: The dean's list is a scholarly award for students who demonstrate academic
excellence. The award at TWU is based on GPA at least 3.5
Organization/Award Name: DEAN'S LIST
Date: 2020 FALL
Description of award: The dean's list is a scholarly award for students who demonstrate academic
excellence. The award at TWU is based on GPA at least 3.5
Organization/Award Name: DEAN'S LIST
Date: 2021 SPRING
Description of award: The dean's list is a scholarly award for students who demonstrate academic
excellence. The award at TWU is based on GPA at least 3.5
Organization/Award Name: Phi Upsilon Omicron, Alpha Alpha Chapter
Date: 2019 FALL
Description of award: The reason why I became a member is to meet the one of qualifications for
membership: ranks not lower than the highest thirty-five percent of their class in general scholarship.
Sports and Extracurricular Activities (copy and paste
next four rows as needed)
Sport/Activity: Church activity
Hours per week: 3
Dates: 05/06/2018 - 03/15/2020
Hours per year: 150
Description of Sport/Activity: Helping to take care of the children during Sunday worship
Certifications (copy and paste next three rows as
needed)
Type of certification: 1 - Stage 1; CITI Conflicts of Interest
Certifying organization: The Collaborative Institutional Training Initiative
Date: January 8, 2021
Type of certification: 1 - Basic Course; Post-Approval Monitoring (PAM)
Certifying organization: The Collaborative Institutional Training Initiative
Date: January 8, 2021
Type of certification: 1 - Lab Animal Research; Working with the IACUC; Investigators, Staff and
Students
Certifying organization: The Collaborative Institutional Training Initiative
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Date: January 8, 2021
Type of certification: Certificate of Membership
Certifying organization: Academy of Nutrition and Dietetics
Date: September 19, 2018
Work experience (copy and paste next six rows as
needed)
Employer Name: EC Ships
Supervisor name: Sarah Wong
Title: Warehouse keeper
Supervisor title: Warehouse Supervisor
Dates: 11/5/2020 - 1/12/2021
Supervisor phone: (940) 220-8838
Number of weeks: 8 weeks
Supervisor email: info@ecships.com
Hours/week: 20 hours
Key responsibilities: Following the company’s warehouse management process, responsible the goods
receiving, issuing and stocking, ensuring the account, mark and stock accurate
Volunteer experience (copy and paste next six rows as
needed)
Employer Name: Royal Care Home Health Care Aide
Supervisor name: Jesse Banham
Agency
Title: Nutrition Counselor
Supervisor title: Administrator
Dates: 09/01/2021 - present
Supervisor phone: (718)772-6012
Number of weeks: N/A
Supervisor email: jbanham@royalcare.nyc
Hours/week: 6
Key responsibilities: Via one-on-one virtual counseling sessions with Chinese-speaking clients to
improve lifestyle-behaviors, anthropometric measures, and metabolic status.
Employer Name: International Chinese Nutrition
Young Scholar Network
Title: Event planning assistant
Supervisor name: Shalin Ma
Supervisor title: Chair of Training and
Communication Committee
Supervisor phone: +86-135-8173-7351
Supervisor email: Michael.ma@jiyanghealth.com
Date: 08/15/2021 - present
Hours/week: 4
Number of weeks: N/A
Key responsibilities: Assist in the preparation of
nutrition and health related activities; Assist in the
invitation of experts in nutrition lectures; Write activity
reports and summaries
Employer Name: University of North Texas
Title: Animal surgery assistant in Mechanism and
Treatment of epilepsy
Date: 01/10/2021- present
Hours/week: 5
Number of weeks: N/A
Key responsibilities: Assist in dissecting the head of the
rat and insert the tungsten electrode in the brain.
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Supervisor name: Lin Li
Supervisor title: Assistant Professor
Supervisor phone: 940-369-8707
Supervisor email: Lin.Li@unt.edu
Employer Name: Texas Woman's University, CARE
Title: Food delivery worker
Date: 11/21/2020
Hours/week: 3
Number of weeks: 1
Key responsibilities: Receive 600 meals donated from
the church,load the car,deliver to a place and distribute
the meals.
Employer Name:Our Daily Bread
Title: Kitchen assistant
Dates: 02/07/2020 - 02/14/2020
Number of weeks: 2
Hours/week: 5
Supervisor name: Amy O’Keefe
Supervisor title: Executive Director
Supervisor phone: (940) 898-2789
Supervisor email: AOkeefe@twu.edu
Supervisor name: Alva Santos
Supervisor title: Volunteer Coordinator
Supervisor phone: (940) 566-1308
Supervisor email:
ourdailybreaddenton@gmail.com
Key responsibilities:Prepare various foods in the
kitchen, serving food and clean up the kitchen
Experience for Academic Credit (copy and paste next
six rows as needed)
Employer Name: N/A
Title:N/A
Dates:N/A
Number of weeks:N/A
Hours/week:N/A
Key responsibilities:N/A
Supervisor name:N/A
Supervisor title:N/A
Supervisor phone:N/A
Supervisor email:N/A
Professional Memberships
Professional Membership Name: Academy of Nutrition
and Dietetics
Description: The Academy of Nutrition and
Dietetics is the world's largest organization of
food and nutrition professionals
Dates: 9/19/2018
Professional Membership Name: Texas Academy of
Nutrition and Dietetics
Description: The Academy of Nutrition and
Dietetics is a not-for-profit professional
organization of over 4,000 registered dietitians,
dietetic technicians, and students in Texas.
Dates: 9/20/2018
Professional Membership Name: International Chinese
Nutrition Young Scholar Network
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Description: International Chinese Nutrition
Young Scholar Network is a non-profit
organization formed by global Chinese nutrition
experts with the purpose of spreading the
evidenced-based nutrition to the world
Dates: 11/1/2018
Professional Membership Name: Food and Nutrition
Networking
Description: The TWU FNN is a student-led
organization open to students in all Nutrition
and Food Sciences programs
Dates: 09/25/2021
Professional Conferences, Symposiums, and
Workshops
Conference Name: The Dietetic Internship
Preparation Workshop
Description: The Dietetic Internship
Preparation Workshop is a student run event
created to help dietetic students prepare for
their dietetic internship.
Dates:10/30/2021
Conference Name: Addressing Hunger and Nutrition
Security: The Social-Cultural and Economic
Dimensions of Sustainable, Healthy Food Systems
Description: Registered dietitian, speaker, and
author, Clancy Harrison, MS, RDN, FAND, and
food futurist, author and speaker, Jack Bobo, will
discuss sustainable, healthy diets in the context of
the social-cultural and economic dimensions in
our current food system and describe the role that
animal source foods play in sustainable, healthy,
culturally relevant dietary patterns.
Dates: 09/28/2021
Personal Statements (These will be written for each program you apply. They will be uploaded to
DICAS and individually directed to the specific program.)
Resume (For this class assignment, attach your current updated resume to this application!)
Date Uploaded:
File Name:
References: I hereby give DICAS permission to contact the reference below via email notification. If my
reference does not submit an online reference form to DICAS in response to the email request, it is my
sole responsibility to contact the reference directly to ensure all references required by my designated
Internship Programs are received by the deadline:
I hereby give permission to the Internship Program to which I am applying to contact the Reference either
to verify the information I provided and/or for further clarification of the information I provided, if
necessary: (duplicate as necessary)
Request Type:
8
Name:
Title:
First Name:
Last Name:
Middle Name:
Email Address:
Phone:
Request Type:
Name:
Title:
First Name:
Last Name:
Middle Name:
Email Address:
Phone:
Request Type:
Name:
Title:
First Name:
Last Name:
Middle Name:
Email Address:
Phone:
Application Certification:
I certify that all the information and statements I have provided in this application are correct and
complete. I certify that, as required, I have read all application instructions, identified all sources of
information related to my college attendance and credits, and noted all actions by a university or other
institution. I certify that the essay(s) submitted with this application is/are my original works. I further
certify that all and any information submitted on my behalf, including letters of recommendation, is
authentic. I have read and understand all notices contained in the application and the DICAS web page
informing me of my obligation to provide true and complete answers to all questions.
I understand that withholding pertinent information or giving false information on this application will be
cause of denial of admission to the internship site participating in DICAS, withdrawal of any offer of
admission, cancellation of registration, expulsion from such school after I have been admitted, or
revocation of my degree. I understand that I have an ongoing obligation to inform the Admissions Office
of any changed circumstances without 30 days of my first notice of such events.
I have read and understand the DICAS Application Deadline Policy and the DICAS Refund Policy. I
understand that DICAS is acting as an agent of the institutions to which I have applied and does not
participate in the admission decisions.
I give my permission to officials at all institutions that I have attended to release information by any
internship site to which I have applied. I understand that my application and materials submitted with my
application become the property of the school(s) of public health, or any other health profession
association to which I have applied. I allow the release of my application materials to persons within the
internship sites to which I have applied. I understand that all information furnished in conjunction with
this application will be treated confidentially and will be disclosed only to officials having a legitimate
educational interest.
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I realize that the institution reserves the right to withdraw an offer of admission if I fail to maintain
satisfactory scholastic standing for work in progress or if final records fail to show completion of courses
and/or degrees required for admission.
Signature: _____Haiyan Huang___
Date: _____9/27/2021___
Designations:
In this space, the names of programs you want to apply to are listed (not in ranking order), such as:
Texas Health Presbyterian Hospital - Dallas, Texas
Baylor University Medical Center – Dallas, Texas
Medical City Healthcare - Coppell, Texas
Abilene Christian University - Addison， Texas
Texas Woman's University Dietetic Internship - Denton, Texas
University of Texas Southwestern Medical Center – Dallas, Texas
10