Memorandum of Understanding
Applicant Instructions: Fill out required information below prior asking a prospective preceptor
to sign. Signed form must be submitted with application for Applied Nutrition – Dietetics
emphasis in GradApp.
For the 2021-2022 program, students will complete Community Nutrition supervised
experiential learning in the fall semester, from August 23 – December 8
th
(16 hours/wk, 240
hours) and Food Service Management supervised experiential learning in the fall semester from
August 23 – December 8
th
, (16 hrs/wk, 240 hours). Students will complete Clinical Nutrition
supervised experiential learning in the spring semester, from January 12
th
– May 4
th
(24-32
hrs/wk, 360-480 hours).
I have agreed to serve as the primary site preceptor for University of Arizona, Applied Nutrition
– Dietetics Future Education Model Graduate (FEM-G) program:
Applicant Name: _______________________________________________________________
Preceptor Name: _______________________________________________________________
Facility Name and address: _______________________________________________________
Supervised Experiential Learning Type: ______________________________________________
Dates: ________________________________________________________________________
The Applied Nutrition – DIETETICS FEM-G program requires that all primary preceptors
complete a formal evaluation of the student’s level of specific competencies, as is required for
compliance with standards set by the Accreditation Council for Education in Nutrition and
Dietetics (ACEND). Additionally, I understand that hours of supervised practice under my
supervision must be verified. While at my facility, I understand that that student will carry
malpractice insurance, as is required under the Applied Nutrition – Dietetics FEM-G program.
These arrangements can be modified or terminated by either party with adequate lead-time to
identify a replacement site for the scheduled student. If the applicant is accepted in the
University of Arizona Applied Nutrition – Dietetics FEM-G program, I understand that an
Affiliation Agreement will need to be established between the University of Arizona and the
facility at which I am employed; I have discussed this with my human resources office and key
administrative executives to ensure that my facility is supportive of my decision to oversee the
intern.
Under this role I agree to provide supervised practice training experience for the graduate
student and coordinate additional learning opportunities associated with my organization.
I have read and agree with the above.
________________________________ ________________________________
Preceptor Name Preceptor Signature & Date
_________________________________ ________________________________
Applicant Name Applicant Signature & Date
