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Master of Professional Practice in Dietetics

 

Preceptor Form

Please fill out separate preceptor application forms for each preceptor in the facility; only one facility form is needed per facility.

Please choose which option best applies to the preceptor filling out the form -




Date
Dietetic Intern Applicant's Name (if known)
First Name Last Name
Preceptor Information
Preceptor First Name Preceptor Last Name
Position Title Credentials
Phone Number Extension:
Email
I have a current CDR Registration ID Number Yes No
What is the highest level of education you have completed?
Facility Name
City State
Is there an Affliation Agreement in place for your facility? Yes No Unknown
Employed Full time Part time *
*If part-time is there another (or several other) preceptor (s) that will be available to assist in mentoring the intern when you are not working? Yes No
Number of years of experience post credentialing (if applicable):
<1 yr     1-5 yrs  6-10 yrs     >10 yrs
Do you have prior experience precepting a dietetic intern? Yes No
Have you previously served as a preceptor for an ISU Dietetic Intern? Yes No
If yes please list the intern's name and year Year
First Name: Last Name:

PRECEPTOR RESPONSIBILITIES

  • Working with the intern to schedule learning experiences during the rotation
  • Assisting in orienting the intern to the facility and rotation, and evaluating oral presentations  (note these duties can also be delegated to other preceptors/staff at the facility)
  • Evaluating intern using form provided
  • Being familiar with and abiding by the ISU Dietetics Internship policies and procedures
  • Acting as the point of contact in the facility for the ISU Dietetic Internship Director and Instructors
  • Mentoring and providing daily supervised learning experiences for intern

My name, credentials, and facility may be posted on the Dietetics Internship website for applicant review.

 Yes No

I have completed the optional 1 CPE ISU DI Preceptor Training available at http://www.dietetics.iastate.edu/preceptors/preceptor-training/

 Yes No

Memorandum of Understanding and Verification of Review

Clicking submit indicates that:

  1. I verify that I have reviewed the Iowa State University Dietetic Internship website: http://www.dietetics.iastate.edu/
  2. I have read and understand the Preceptor responsibilities and I agree to the terms.
  3. If the applicant named below is selected for the Iowa State University Dietetic Internship, I agree to fulfill the expectations of serving as a preceptor for the intern listed at the top of this form.
  4. I agree that the purpose of the supervised practice is for education and I will not use interns to replace employees.
  5. I understand that the purpose of the affiliation agreement is to protect the intern, client/patient/customer, preceptor and facility and ISU. In the event no agreement is entered into by the parties, each party in the shadow/observation-only experience will be responsible for the liabilities arising out of their own conduct and the conduct of their officers, employees and agents.

Please email a copy of your resume to diapply@iastate.edu When emailing your resume the subject line should be "Preceptor Resume Submitted"

Please print a copy for your records before clicking submit.

Affiliation Agreement Process

After interns are selected in late April or late November, the Program will send the Primary Preceptor of each practice site/facility an “Iowa State University Affiliation Agreement.”  While most agreements are not signed until a student has been offered and accepted an appointment, practice site/facility administrators should be aware of the content of this essential document early in the application process.  After a student accepts an internship appointment, appropriate practice site/facility administrators will be asked to sign this agreement with Iowa State University by June 1 if the intern will participate in the JUNE internship class or by January 1 if the intern will participate in the JANUARY internship class as a condition of the student’s final acceptance into the internship.

If you have questions, please contact diisu@iastate.edu