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Nutrition & Dietetics: Online Internship Form

Supervised Practice Facility Information

Distance Dietetic Internship

Note: All fields are required.

Intern Name:
Type of Affiliation (please check):
Foodservice Nutrition Therapy Community
Name of Facility:
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:



Nutrition & Dietetics Dept. | O'Neill Center for Healthy Families, Room 221 | (570) 348-6277 |