Fillable Mdn Pdi Recommendation Form

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Mdn Pdi Recommendation Form

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Recommendation Form: Dietetic Internship and Graduate School
Applicant name: ______________________________________________________________________________________________
Reviewer name: ______________________________________________________________________________________________
In what capacity are you completing this form (select all that apply):
Employer Preceptor Adviser Program Director Faculty
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
Works in teams effectively
Reaction to conflict
Leadership potential
Initiative and motivation
Punctuality
Adaptability
Reaction to stress
Perseverance
Resourcefulness and creativity
Organizational skills
Works independently
Emotional maturity
Integrity
Analytical skills/problem solving
Conceptual skills
Tolerance to others
2. Based on your observations of the applicant in the setting identified above, 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)
c. Food Service Management (Includes ability to develop menus, budgets, quality improvement projects, enforce
and model food safety and sanitation practices, implements process and procedures correctly, identifies
efficiencies in process, mentors others in these practices)
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 Recommendation Form

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Completed 14 February 2020

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