Fillable Mdn Non-paid Work Experience Form

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Mdn Non-paid Work Experience Form

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Non-Paid Nutrition-Related Experience Verification Form
Applicant: _______________________ ______________________ _____________________
Last Name First Name Middle Name
Date of Birth (MM/DD/YY): ______________________________________________________
The UD MDN program and Premier Dietetic Internship program require a minimum of 200-hours
of nutrition related work experience. 100-hours of this experience can be unpaid work
experience. This is not shadowing experience but rather long-term non-paid work experience in
which you are working directly with a dietitian on a project that directly impacts an
organization. One verification form is completed per facility. The supervisor will complete this
form and will email it to Jennifer Dalton, Director of Dietetics at the University of Dayton, at
JDALTON1@UDAYTON.EDU
Facility Name: _________________________________________________________________
Supervising RDN: _______________________________________________________________
Description of Work and Outcomes (to be completed by the supervisor)
Please provide detailed description on the work and projects the student completed for your
organization and the impact of their work to your organization. May continue on page 2 of this
form, or attach additional sheets as needed.
Description of Work and Outcomes (continued from page 1)
Dates of Work:
From (MM/DD/YY): ________ to (MM/DD/YY): _________ Number of hours: _____________
Supervisor Signature:
I hereby verify that the above information is true and accurate.
Supervisor’s Signature: ______________________________________ Date: _____________
Print Name: ___________________________________________________________________
Email: ________________________________________________________________________
Phone Number (incl. area code): __________________________________________________
Please email this completed form to Jennifer Dalton, Director of Dietetics at the University of
Dayton, at JDALTON1@UDAYTON.EDU
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Mdn Non-paid Work Experience Form

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Completed 14 February 2020

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