Dietetic Internship - 1 Year Employee Survey

This questionnaire was designed to assess the knowledge and skills of Southern Regional Medical Center’s Dietetic Internship Program Graduates. We will use this information to improve and adjust our program as warranted. Please use the following questions to assess your employee who recently completed the internship program at Southern Regional Medical Center. Please take 10-15 minutes of your time to complete the following survey. Your cooperation in completing this form is greatly appreciated.

* - required fields

Employee/Graduate Name:  *
Credentials:  * RD  LD   Other  
Dates of Employment:   To         
Agency: 
Type of Position:  *  
Evaluator: 

Please select the number in the “Ratings” column which most closely corresponds with the employee performance in the given area according to the following descriptions:

5 Outstanding performance; exhibits initiative and ability that substantially exceeds expectations.
4 Above average performance; exhibits ability above general expectations.
3 Average performance; satisfies general expectations
2 Less than average performance; much improvement needed
1 Unsatisfactory performance

 
Performance - Rate competency and knowledge of your employee in handling his/her current position.  * 12345
Comments: 
Planning and Organizing - Sets personal objectives; schedules time to achieve objectives; correlates all objectives; obtains and utilizes resources; prepared for clients and group sessions; assignments completed timely.  * 12345
Comments: 
Gathering and Evaluating Data - Works within policies and procedures of agency, obtains, analyzes and provides accurate nutrition information, develops and implements individual nutritional care plans, explain interrelationships of data, make appropriate changes, analytical and problem-solving ability, use of research and evaluation methods.  * 12345
Comments: 
Applying Scientific Principles of Nutrition - Recognizes all factors affecting nutritional needs, accurately interprets data based on current nutrition theory and knowledge, individual and realistic care plans, utilizes appropriate references, implements nutritional care plans and evaluates effectiveness.  * 12345
Comments: 
Oral and Written Communications - Addresses clients at level of understanding, establishes open communications, listens effectively, expresses questions and information appropriately, uses appropriate body mannerisms, documents correctly, expresses written thoughts clearly and neatly, uses appropriate literary style, writing consistently free of errors.  * 12345
Comments: 
Human Relations - Establishes rapport with clients, faculty and peers, demonstrates appropriate conduct, content of questions and comments appropriate, establish open communications, listens effectively, functions as a team member.  * 12345
Comments: 
Teaching Skills - Advance preparation; follows teaching-learning guide (objectives, etc.), utilizes appropriate resources (visuals, etc.), appropriate time and setting, establishes rapport, teaches at appropriate level of understanding, exhibits creativity and resourcefulness, seeks and uses learning opportunities, stimulates learning.  * 12345
Comments: 
Acceptance of Responsibility - On time, prepared for assignments, cooperative, reliable, utilizes time efficiently, follows directions; manages responsibilities within a day, flexible, indicates unfinished work and follows through, recognition of learning process.  * 12345
Comments: 
Professional Performance - Maintains ethical standards, respects others’ confidentiality, seeks additional learning opportunities, adheres to agency policies, personal appearance, professionally dressed, well groomed.  * 12345
Comments: 
Management Skills - Manages resources efficiently, establishes short and long term goals and objectives, pursues innovative methods in daily practice, seeks new ways to improve productivity and revenue, has good managerial skills.  * 12345
Comments: 

Please answer the following by selecting either yes or no and completing the blanks as appropriate.

1.  Does employee currently conduct and/or participate in any research activities?

 Yes No
If yes, please describe: 

2.  Is employee currently involved or participate in Journal Club via the place of business, association, internet, or individually?

Yes No
If yes, how: 

3.  Is employee currently involved in National, State, or Local Professional Associations?  *

  Yes No
If yes, which ones?

Is employee registered?  *

  Yes No
If no, please indicate why not: 

4.  Is employee licensed?  *

  Yes No
If no, please indicate why not: 

5.  Has the employee obtained any credentials or certifications since graduation?   *

  Yes No
If yes, please list.