Lenoir-Rhyne University
Solmaz Institute for Obesity (SIO)
Dietetic Internship Program
Nationwide Option
Supervised Practice Facility Information Form
Internship applicants must submit a separate completed and signed Supervised Practice Facility
Information Form for each facility where they will undertake a supervised practice experience of
one week of more. Each student must have a preceptor in the facility for all such experiences.
After interns are selected in June, the SIO DI Program will send the Primary Preceptor of each
practice site a “ Lenoir Rhyne University Affiliation Agreement.” While agreements are not
signed until a student is offered and accepted an appointment, practice site administrators
should be aware of the content of this essential document. After the student accepts an
internship appointment, the appropriate practice site administrators will be asked to sign this
agreement with Lenoir Rhyne University by July 1st if the intern will participate in the Fall DI
program, as a condition of the student’s final acceptance into the internship.
Student Applicant’s Name:
Facility Contact Information
Facility name:
Address, include city, state, zip code:
Facility phone number, including area code:
Name, phone number, fax number and title of facility’s Contract Officer, Business Officer or
approved designee:
Name of the preceptor(s) for rotations occurring at this facility:
Has the preceptor(s) from this facility completed a preceptor application? ___YES___NO
Total Dietitians (RDs) :__________
Advanced Degree RDs:______________
Total Diet Techs (DTR): _________________
To what extent does the facility practice the Nutrition Care Process (NCP)?
____ To the full extent
____ Some
____ Not at all
Would this facility like more information on the NCP? ___ YES
____ NO
Maximum number of interns from this program in this facility at one time:
during one year:
Length of time students from this program assigned to this facility:
Maximum number of dietetic intern from this and other programs in this facility at one time:
Adapted from Iowa State University at Ames
Which SIO Internship rotations will be completed at this facility (check all that apply):
Administrative ( 6 weeks)
 Purchasing &
inventory
 Foodservice
 Food Production
 Administration
 Marketing
 Food service staff
experience (2 weeks)
 School Nutrition
Education
Clinical (14 weeks)
 Clinical Inpatient Care
(7+ weeks) includes:
 Renal
 Nutrition
Support/Critical
Care
 Pediatrics
 Long-term care
(1-2 weeks)
 Outpatient care
(1-2 weeks)
 Clinical Staff Relied
( 2 weeks)
Community (10 weeks)
 Public Health Nutrition
 WIC
 Child and Adolescent
Weight Management
 Community Staff Relief
(2 weeks)
Check which resources would be available to SIO interns while training at this facility:
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Computer or laptop
Internet connection
Word Processing (MS Word)
Spreadsheets (MS Excel)
Computer access through company
network
Email
Teleconferencing
Computerized Diet Analysis
Copier/fax machine
Office or work space
Telephone
A/V equipment to teach
classes/presentations
Training room
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Resource books- clinical
Resource books- public health
Resource books- Food service
Trade journals
Reference manuals
Professional journals
Medical or Central library
Other resources:_________________
Other technology : _______________
Meals
Company Transportation
If this facility will provide a foodservice systems/administrative experience for the intern,
please answer the following:
Name of Food Service Director:
Basic type of operation ( e.g. cook-chill, conventional, etc):
Number of FTE’s:
Number of meals served per day:
Check the foodservices that are provided in this facility
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Cafeteria
Meals on wheels/delivery off site
Restaurant style
Catering
Employee meals
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Patient/resident tray
Patient/client dining room
Snack bar/vending/a la carte
USDA Hot lunch Program
USDA Breakfast Program
Other: _________________________
Adapted from Iowa State University at Ames
Supervised Practice Experiences included in this facility, please check all that apply.
Nutrition assessment and education in common
medical conditions
Nutrition assessment, patient care and education in
complex medical conditions
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Food service systems approach to operation and
management of food service operation
Study, application, and evaluation of methods,
techniques and tools used by the community
nutritionist
Diabetes
Weight Management Adult
Weight Management Child/adolescent
Digestive and Intestinal disorders
Pregnancy
Adult wellness
Preventative and rehabilitative cardiac
services
Geriatrics
Acute and Chronic cardiology
Oncology
AIDS/HIV
Other disorders of the immune system
Pediatrics
GI disorders
Med/Surg ( ex: hepatic, pancreatic
disorders)
Pulmonary conditions
Critical Care
Renal disorders
 Recipe/menu development and
modification
 Supply procurement
 Food production and service systems
 Sanitation and safety
 Quality Management
 Management tools, functions, skills,
resource management
 Information management and reporting
 Training and education
 Program planning, management,
leadership, budgeting, social marketing
and evaluation
 Consideration of legislation and nutrition
policy
 Federal and non-governmental agencies
 Consumer and advocacy groups
 Other professional and service
organizations designed to provide food and
nutrition services and information
 Child and adolescent weight management
___________________________________________________________________________________
Signature of Facility Contract or Business Officer or approved designee:
Date:
Adapted from Iowa State University at Ames