Completed Internship application form (DEP) 3

Dietetic Internship Program Application Verify application requirements of each program to which you wish to apply Not all programs use this form All information must be typed/printed Date 11/16/2015      Name Elwell      Nancy Anne Thorson (Last) (First) (Middle or Maiden) Present Address 6300 SW Grand Oaks Drive      C103 (Street) Corvallis (City) Permanent Address (Apt #) Oregon 97333 970-631-7666 (State) (Zip Code) (Phone)       (If different)       (Street)       (City) (Apt #)                (State) (Zip Code) (Phone) 970-631-7666      970-631-7666 Cell Phone Number (Phone number where you can be reached on Appointment Day.) nancyjim88@yahoo.com      ***-**-**** E-mail address Social Security Number May 2016      May 2016 Actual or Expected Date (Month/Year) Baccalaureate Degree conferred Actual or Expected Date (Month/Year) DPD Course requirements completed       Foreign Applicants: Designate Immigration Status Grade Point Averages: Graduate Record Exam Results: (If taken, include a copy with your application.) · Not all programs require GRE scores · Check each program’s admission requirements · Leave blank if not applicable Expiration Date:       3.56      3.4            Overall Undergraduate (See page 6.) DPD (See page 6.) Overall Graduate (If applicable)                         Date Taken (Month/Year) Verbal Score Quantitative Score Analytical Writing Score Use the following steps with Word 2007, to unlock this document so it is editable, i.e you are able to modify box sizes, font etc Page of 12 Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs 1 Open the file in Word Click on Review tab (at top of page) Click on Protect Document (usually at far right) Click on Restrict Formatting and Editing Click on Stop Protection The form is now unlocked and editable Treat it as you would any table in a Word document After making edits, click on “Yes, Start Enforcing Protection” When the dialog box appears, just click “ok” without entering anything into the password fields This allows you to once again jump between fields with the tab key and the drop down boxes, work as intended Page of 12 Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs 8 Education: List all colleges or universities attended, with most recent listed first City and State of Start and End Dates College/University College/Univeristy (Month/Year) Degree University of Northern Colorado      Greeley, CO      01/14-05/16 Dietetics Oregon State University      Corvallis, OR 09/10-08/13 Colorado State University Fort Collins, CO 06/87-12/91 None Political Science                                                       Recommendations: List the names of the individuals who will complete your recommendation forms Name Title Address E-mail and Phone       Assistant Professor Coni Francis PhD, RD      Nutrition and Dietetics Program    Catherine Gerweck, DMD, MS, RDN      Instructor UNC  Caroline Love     Vice President of Operations University of Northern CO Gunter 2280 Campus Box 93 Greeley, CO 80639    University of Northern CO Gunter 2280 Campus Box 93 Greeley, CO 80639        Hampton Creek 371 10th Street San Francisco, CA 94103 Email:   constance.francis@unc.edu     Phone: 970-351-1489      Email:   catherine.gerweck@unc.edu     Phone: 970-351-2755    Email:   cvlove@gmail.com     Phone: 844-423-6637     Honors and/or extracurricular activities after beginning college: List organizations, appointed or elected offices held, scholarships, honors, and certifications received Include dates for honors    Golden Key Honor Society  07/15    ServSafe Certification 07/15                                                 Professional Organization Memberships: List professional organizations of which you are a member     Academy of Nutrition and Dietetics      Oregon Academy of Nutrition and Dietetics              Page of 12 Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs                   Page of 12 Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs Work experiences in the past five (5) years: List all experiences, including volunteer, beginning with the most recent Indicate if the experience was paid, volunteer or part of a practicum/field experience associated with a college course Briefly describe key responsibilities When indicating the amount of hours, use hrs/wk for reoccurring work and volunteer experiences and total hours for limited time volunteer and practicum/field experiences (Note: if you have professional dietetics work experience from over five years ago, you may include it.) Use additional pages as needed Name of Employer / Organization Position Title Start and End Dates (Month/Year)   Hampton Creek/ Food Start-Up    Relationship Specialist      1/14-8/15      Supervisor’s Name and Title:  Melanie Myers/Corporate Partnerships Team      Key Responsibilities:       Sales and marketing of food products Traveled to trade shows to promote products Good Samaritan Regional Medical Center      Dietetics Volunteer      8/13-1/14     Supervisor’s Name and Title: Sara Thomas MS, RD, LD/Nutrition Manager      Key Responsibilities:       Assisted with research, appointment setting, reviewing recipes, and Oncology Lending Library Samaritan Pacific Communities Hospital       Practicum      8/13, 03/15     Supervisor’s Name and Title: Erin Dooher RDN, LD/Dietitian      Key Responsibilities: Shadowed dietitian on clinical rounds Attended diabetes education class, observed nutrition counseling sessions, observed charting in Epic, and reviewed case files prior to rounds   2 Hrs/Wk    Volunteer Email: sathomas@samhealth.org    Vol  Phone: 541-768-5422      15 Hrs/Wk, 12 Practicum Hrs/Wk      Email: edooher@samhealth.org       Phone: 541-574-1815            Corvallis Environmental Center      Event Planner  4/13-5/13     Supervisor’s Name and Title: Jena Botte/ECI Outreach Coordinator       Key Responsibilities:       Planned events, solicited and collected donations, made event baskets, and did research Oregon State University/Cascadia Market       Customer Service/Food Prep     Supervisor’s Name and Title: Jim Hoffman/Manager       Page of 12 Hrs/Wk Paid, Volunteer, or Total Hours or Practicum 20-40 Paid Hrs/Wk      Email: mmyers@hamptoncreek.com      Phone:  832-457-6326       08/11-09/13    37 Total Hours Volunteer       Email: corvallisenvironmentalcenter.org       Phone: 541-753-9211      20 Hrs/Wk      Paid Email: jim.hoffman@oregonstate.edu       Phone: 541-737-3696      Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs Key Responsibilities: Prepped food, served customers, cleaned, opened and closed market       Market of Choice      Customer Service Clerk      Supervisor’s Name and Title:  Cody Whitlock/Assistant Manager      09/10-03/11     20 Hrs/Wk      Paid Email: codyw@marketofchoice.com      Phone: 541-758-8005      Key Responsibilities:       Put together food orders for delivery, customer service, cleaning, and facing shelves Page of 12 Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs Work experiences in the past five (5) years, continued Place of Employment and/or Practicum  Benco     Position, Title Start and End Dates (Month/Year) Direct Client Care 03/10-09/10      Supervisor’s Name and Title:  Rachel Derry/Supervisor     Key Responsibilities:       Assisted disabled clients in their home with activities of daily living Cooked meals, administered medications, provided transportation, and charted log notes Mutual of Enumclaw Insurance Company      Claims Adjuster II        04/08-08/09    Supervisor’s Name and Title: Jason Murdock/Liability Claims Examiner      Key Responsibilities: Interviewed clients, managed injured client case files, investigated liability, reviewed medical records, explained benefits, interpreted policies, set up appointments and made referrals   Special Claims Representative    06/92-06/07      Supervisor’s Name and Title:     Kathy Meisner/Liability Supervisor                    Email:       Phone:       Supervisor’s Name and Title:             11       Supervisor’s Name and Title:       Page of 12 40-45 Paid Hrs/Wk      Email: kathy.meisner@farmersinsurance.com       Phone: 970-225-9306            10       Key Responsibilities: 40-45 Paid Hrs/Wk      Email: JMurdock@mutualofenumclaw.com       Phone:360-825-2591             Farmers Insurance      Key Responsibilities: Interviewed clients, managed injured client case files, investigated liability, reviewed medical records, explained benefits, interpreted policies, set up appointments and made referrals Hrs/Wk Paid, Volunteer, or Total Hours or Practicum 16-20 Paid Hrs/Wk      Email: racheld@bencocorvallis.com       Phone: 541-231-4929                        Email:       Phone:       Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs Key Responsibilities:       12             Supervisor’s Name and Title:       Key Responsibilities: Page of 12             Email:       Phone:             Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs Didactic Program in Dietetic (DPD) Courses: Include all courses required to meet DPD requirements at your college or university If a course has not been completed, indicated INC in the No of Credits column See instructions on page Use additional pages as needed (If you have earned credits from multiple educational systems that use different credit units, e.g semesters and quarters, you must convert all credits to one type of unit.) College or University  Oregon State University      Oregon State University    Course Prefix & No Course Title Lab / Practicum Managing Organizations No Promoting Food & Nutrition No Principles of Biology Yes Z 331      Human Anatomy/Physiology      Yes, Z 341 Fall 2012      Z 332      Human Anatomy/Physiology      Yes, Z 342 Winter 2013    Z 333      Human Anatomy/Physiology      Yes, Z 343 Spring 2013      Intro to Microbiology Yes General Chemistry      No General Chemistry      Yes General Chemistry      Yes Organic Chemistry      No Organic Chemistry       No Elementary Bio-Chemistry No Medical Terminology No BA 351      NUTR 319       Oregon State University      BI 212      Oregon State University Term & Year No of Credits Spring 2013      Spring 2011      Winter 2012      2.67       2.0       2.67       1.33 lab 2.0 class 1.33 lab 2.0 class       1.33 lab 2.0 class       2.67       3.33       3.33       3.33       2.67       2.67       2.67       2.0       0.67 lab 2.0 class       2.0       0.67 lab 3.33 class       1.0 lab 2.0 class       Oregon State University  Oregon State University      Oregon State University       Oregon State University       Oregon State University      Oregon State University      Oregon State University       Oregon State University    Oregon State University      University of Northern CO      MB 230      CH 121      CH 122      CH 123      CH 331      CH 332      BB 350      FND 210      Spring 2011      Fall 2010      Winter 2011      Spring 2011      Fall 2011      Winter 2012      Spring 2012      Spring 2014       Oregon State University      NUTR 240      Human Nutrition Yes, NUTR 241 Winter 2011       Oregon State University     NUTR 325      Nutrition Through Life Cycle      No Fall 2011       Oregon State University     NUTR 235        Science of Foods    No Fall 2012       University of Northern CO      FND 320      Nutrition Applications in Food Service Yes Summer 2015       University of Northern CO       University of Northern CO      FND 370      FND 410      Nutrition Education and Application Strategies Professional Development Seminar Page of 12 No No Fall 2014      Fall 2015      Grade Earned Grade Points Earned B      8.01       A 8      B+       8.01       CB-      2.66 6      B A-      3.99 8      B+ C+       3.99 4      A      C      C      AC      B      B-      10.68       6.66       6.66       13.32       5.34       8.01       8.01       A 8      A A      2.68 8      A      8      AA-      2.68 13.32       A A      3.0 A 12 INC                   Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs  University of Northern CO      FND 430      Nutrition Assessment and Intervention Yes Fall 2014       University of Northern CO      FND 431      Medical Nutrition Intervention Yes Spring 2015      University of Northern CO      University of Northern CO      FND 451      FND 452      NUTR 311      PSY 202      SCI 291      STAT 150      FND 420      FND 455            Advanced Nutrition No Community Nutrition No Food Service Production and Purchasing      Yes General Psychology No Scientific Writing No Intro to Statistical Methods Yes  Oregon State University       Oregon State University       University of Northern CO       Oregon State University       University of Northern CO      University of Northern CO                         Maternal and Child Nutrition     Nutrition For Fitness and Athletic Performance                  No No Spring 2015      Summer 2015      Winter 2013      Fall 2010      Summer 2015      Summer 2013      Fall 2015      Fall 2015                  Totals Credits 1.0 lab 3.0 class       1.0 lab 2.0 class       3.0       3.0       2.67 2.0       3.0       2.67       INC       INC                   78.21       A B      9      A A A 12 A      A A A-      B      12       10.68       8      12       8.01                                                       Total Grade Points 265.71       I certify the information I have provided in this application is true and accurate and recognize any false or incorrect statements made herein will be grounds for my dismissal from the program I understand I must provide an original copy of a signed Verification Statement substantiating completion of academic requirements prior to start date of program Nancy Elwell 11/18/15      Date Page 10 of 12 Signature Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs Instructions for Completing Grade Point Averages CALCULATING UNDERGRADUATE GPA: (If you have earned credits from multiple educational systems that use different credit units, e.g semesters and quarters, you must convert all credits to one type of unit.) ·Example – Pat completed all courses required for an undergraduate degree in nutrition from one university o Pat should use the calculated GPA on the institution’s transcripts ·Example - Sarah earned an undergraduate degree in sociology with a minor in nutrition She attended two community colleges and a state university to fulfill all degree requirements She took several general interest courses while attending these colleges, although the courses did not meet any specific degree requirements These courses are listed on her transcripts Sarah also took a ceramics class at a fourth community college during one summer It was the only course she took from this college and is not one of the three colleges she attended to meet her degree requirements Sarah will calculate the Undergraduate GPA using the transcripts from the three institutions she attended where she earned credits towards her undergraduate degree Because Sarah did not transfer her ceramics course grade to her degree granting institution, it will not be included in the Undergraduate GPA calculation General interest courses Sarah took from the three credit earning institutions will be included College/University Credits GPA From Transcripts Grade Points Earneda 15 3.90 College/University Credits GPA 24 58.5 a College/University Credits GPA 2.90 69.6 To calculate Grade Points Earned, multiply the number of credits times the GPA for each respective institution separately b To calculate the Undergraduate GPA; divide the Total Grade Points Earned by the Total Credits In this example: 423.58 ÷ 128 = 3.31 89 3.32 295.48 Total Grade Points Earned = 423.58 Total Credits = 128 Undergraduate GPAb = 3.31 CALCULATING DPD GPA: Each university has specific courses which meets Didactic Program in Dietetics (DPD) requirements The DPD Director at the university where you earned or will earn the Verification Statement indicating you are eligible to apply to a dietetic internship will have a list of these courses The following scale should be used to calculate Grade Points Earned for your DPD GPA For repeated courses, list both grades earned but use only the higher grade to calculate the DPD GPA Grade earned A+, A, A- Grade Points Earned for each credit 4.0 B+, B, B- 3.0 C+, C, CD+, D, D- 2.0 1.0 Sample completed form: College or University Course Prefix & No Course Title Lab / Practicum Term & Year No of Credits Grade Earned Grade Points Earned Midtown University Chem 113 Chemistry Fall ‘08 B       Chem 114 Fall ‘08 A-       A&P 202 Fall ‘07 D Fall ‘08 C+ Psych 100 Chemistry Lab Physiology (includes lab) Physiology (includes lab) (retook class) Intro to Psychology Summer ‘08 A 12 Eng 101 English Composition Summer ‘08 B+ Nutr 344 Food Management Spring ‘08 B- Nutr 444 Advanced Nutrition *INC Incomplete - currently enrolled or to be completed Spring ‘09 INC* A&P 202 Centerville Comm College Eastside State University       Totals Credits Page 11 of 12 17       Total Grade Points 51 Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs To calculate DPD GPA, divide the Total Grade Points by the Total Credits In this example: 51 ÷ 17 = 3.00 Page 12 of 12 DPD GPA 3.00 Revised January 2009 Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs  ... 2012      2.67       2.0       2.67       1 .33 lab 2.0 class 1 .33 lab 2.0 class       1 .33 lab 2.0 class       2.67       3. 33? ??      3. 33? ??      3. 33? ??      2.67       2.67       2.67       2.0   ... Yes Z 33 1      Human Anatomy/Physiology      Yes, Z 34 1 Fall 2012      Z 33 2      Human Anatomy/Physiology      Yes, Z 34 2 Winter 20 13? ??   Z 33 3      Human Anatomy/Physiology      Yes, Z 34 3 Spring... by the Total Credits In this example: 4 23. 58 ÷ 128 = 3. 31 89 3. 32 295.48 Total Grade Points Earned = 4 23. 58 Total Credits = 128 Undergraduate GPAb = 3. 31 CALCULATING DPD GPA: Each university