Supervised Practice Facility Information

Distance Dietetic Internship

Note: All fields are required.
Intern Name:
Type of Affiliation (please check):
Foodservice Nutrition Therapy Community
Business/Entrepreneur
 
Other
Name of Facility:
Address:
Facility accredited/licensed by:
Used as a practice site for the following courses/rotations:
Maximum number of interns from this program in this facility at one time:
Length of time interns from this program assigned to this facility:
Maximum number of interns from this and other programs in this facility at one time:
Number of Dietitians: Total RD Advanced Degree
number of dietetic technicians: total DTR
Brief description of facility/agency/institution (mission, population served):
Brief description of department, including services performed, number of employees, and number of individuals served:
Brief summary of experiences provided for intern: