Fillable Mdn Pdi Mnt Instructor Recommendation

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Mdn Pdi Mnt Instructor Recommendation

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Medical Nutrition Therapy Recommendation Form
Applicant name: ______________________________________________________________________________________________
Reviewer name: ______________________________________________________________________________________________
In what capacity are you completing this form (select all that apply):
Employer Preceptor Adviser Program Director
If Dietetics faculty member, list dietetic courses for which you taught this applicant:
__________________________________________________________________________________________
1. Complete the Skills Evaluation Form
5 = Outstanding; 4= Above Average; 3 = Average; 2 = Below Average; 1 = Poor; N/O = Not Observed
Skill
5
4
3
2
1
N/O
Evidence from observations to demonstrate rating
Oral Communication Skills
Written Communication Skills
Pathophysiology
MNT
Exchange System
Evaluation of diet in context to MNT
Nutrition Support to include
calculations
Adaptability
Reaction to Stress
Perseverance
Resourcefulness and creativity
Organizational skills
Works independently
Emotional maturity
Integrity
Analytical Skills/Problem Solving
Conceptual Skills
2. Based on your observations of the applicant in medical nutrition therapy, describe your confidence in their ability to
successfully apply their knowledge and skills in the following areas during their internship and graduate degree program
(type “N/O” if Not Observed):
a. Nutrition Content (Includes ability to retrieve, recall and problem solve utilizing knowledge acquired from the
dietetics curriculum-food science, nutrition science, nutrition health, disease, food service management)
Select One: Highly Confident Confident Reservations Not Confident
Evidence from Observations (class work or evidence of application in the workplace/volunteer)
b. Medical Nutrition Therapy (Includes understanding of pathophysiology, accessing appropriate resources to
complete case studies, ability to implement skills for interventions for GI, Weight Management, Diabetes,
Cardiovascular Disease, Oncology, TPN and EN.
Select One: Highly Confident Confident Reservations Not Confident
Evidence from Observations: (class work or evidence of application in the workplace/volunteer)
3. Complete the Summary Evaluation
Outstanding Recommendation
Highly Recommendation
Satisfactory Recommendation
Recommend with Reservations
Do Not Recommend
Reviewer Signature (in blue ink): ________________________________________________________________________________
Reviewer Printed Name: _______________________________________________________________________________________
Reviewer Phone Number (incl. area code): ___________________ Reviewer Email: ____________________________________
Date: _________________________________________________
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Mdn Pdi Mnt Instructor Recommendation

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Completed 14 February 2020

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