offical seal
Human Capital Management
#180713-Z24A-08


Supplemental Questionnaire

Last Name First Name
 
 

What experience do you have interviewing patients and taking diet histories?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have received education or training from a registered dietician.
I have no experience with this task.
 

Please list the school and location or employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

 

What experience do you have reviewing patient medical charts for dietetic and nutritional information?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have received education or training from a registered dietician.
I have no experience with this task.
 

Please list the school and location or employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

 

What experience do you have assisting a nutrition therapist in determining appropriate nutritional care of patients?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have received education or training from a registered dietician.
I have no experience with this task.
 

Please list the school and location or employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

 

What experience do you have giving individual diet instructions to patients with normal modified diets, as directed by a nutrition therapist?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have received education or training from a registered dietician.
I have no experience with this task.
 

Please list the school and location or employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

 

 

What experience do you have conducting classes on general nutrition and consumer education?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have received education or training from a registered dietician.
I have no experience with this task.
 

Please list the school and location or employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

 

What experience do you have maintaining medical records and preparing reports?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have received education or training from a registered dietician.
I have no experience with this task.
 

Please list the school and location or employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

 

How many years of experience do you have working in a hospital, school, public health department, or institutional setting?

More than 5 years.
Less than 5 years.
I have no experience working in any of the above settings.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
 

Please check all of the following certifications you have obtained.

Diet Technician, Registered (DTR)
Registered Dietician (RD)
Certified WIC Nutrition Technician (CWNT)
Licensed Practical Nurse (LPN)
I have none of the certifications listed above.
 

Please list where you gained your certification as indicated in the response above.  If you indicated "no certification", then please type NA below.