Keene State College Dietetic Internship page 1 of 6

Internship requirements
Intern Name: Claudia Gumina Date: 11/3, Updated , Updated , Updated


List supervised practice settings where you addressed the following conditions
Overweight and obesity - Concord Hospital - Clinical Rotation
Diabetes Cheshire Medical Center - Diabetes Support Group Presentations, Concord Hospital - Clinical Rotation, NH State Hospital
Cancer HHH - Assessed the diet of patients with cancer and related conditions, Concord Hospital - Clinical Rotation, Cheshire Med Oncology Center
Cardiovascular Concord Hospital - Clinical Rotation, NH State Hospital
Gastrointestinal - Concord Hospital - Clinical Rotation
Renal diseases - Concord Hospital - Clinical Rotation
Other conditions specific to your personal learning goals -
List classes, homework, and supervised practice settings where you learned about and/or worked with the following populations
Ethnically diverse Kurn Hattin Teens Presentations, WIC, Concord Hospital
Diverse in abilities or needs (physical or mental) HHH - Older citizens with different needs for assistance, NH State Hospital
Extended care - skilled nursing (includes SNF in hospitals), assisted living, home care, rehab, or other
Low-income, nutritionally at risk women, infants, children - WIC training, WIC clinic, Head Start, EFNEP (Cooperative Ext),
Child care / Adult care Feeding Program, Other Low-income at Concord Outpatient Student Clinic

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Internship Requirements - Community
PRESENTATIONS Site Presentation Title/Topic Completed TL? Documents required in portfolio
Children: Marlborough
Community School
Healthy Eating
Food Advertising
Creating Your Own Food
Commercial

November
12
th
, 19
th
,
and 26
th
.
Site Summary, COP, Presentation Eval
form, Handouts, RCA*, TL report*
Adolescents: Kurn Hattin Homes Sugar-Sweetened Beverages
Food Advertising
January
28
th
and
February
4
th
.
Site Summary, COP, Presentation Eval
form, Handouts, RCA*, TL report*
Adults Phoenix House Physical Activity and Hydration
Food Safety
Added Sugar
July 1
st
, 8
th
,
and 15th
Site Summary, COP, Presentation Eval
form, Handouts, RCA*, TL report*
Elderly: Diabetes Support Group
at CMC
Controlling Portion Sizes March
13
th
, and
April 10
th

Site Summary, COP, Presentation Eval
form, Handouts, RCA*, TL report*
Any age group: TOPS Presentation Spicing Up Your Vegetables July 9th Site Summary, COP, Presentation Eval
form, Handouts, RCA*, TL report*
Any age group: Site Summary, COP, Presentation Eval
form, Handouts, RCA*, TL report*
Rotation Competency Assessment (RCA) required for sites > 20 hours or with 2+ presentations. In some cases the Professional Development Evaluation
(PDE) is used instead. Two team leader reports are required throughout the internship year.


Educational
Handouts
Site Presentation Title/Topic Completed TL? Documents required in portfolio
Children: Marlborough Elementary Food Safety December,
2013
Site Summary*, Educational Material,
Peer Evaluation, Revised Ed. Material
Adolescents: Kurn Hattin Homes Food Advertising February
4
th
, 2014
Site Summary*, Educational Material,
Peer Evaluation, Revised Ed. Material
Adults Phoenix House Added Sugar July 15
th
,
2014
Site Summary*, Educational Material,
Peer Evaluation, Revised Ed. Material
Elderly: CALL Classes Greek Food October Site Summary*, Educational Material,
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28
th
, 2013 Peer Evaluation, Revised Ed. Material
*Most education materials will be completed as part of a presentation/project for a site, they should be mentioned in the site summary for that site.



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Other Community Requirements, Elective, Simulation
Site Presentation Title/Topic Completed TL? Documents required in portfolio
Print media /
article
The Community Kitchen January/February Newsletter January
23
rd
, 2014
Site Summary, copy or link to published
article or newsletter
Electronic media Site Summary, COP, script

Counseling Concord Outpatient
Services, WIC
December
19
th
, 2013
Site Summary, Counseling Skills Eval, PDE

Health Fair or
Event display
Site Summary, COP, Health Fair
Evaluation form
Community trainings and simulation
Phoenix House needs assessment, objectives
writing, and presentation development
training
Simulation 9/6/13 NA NA
Cooking Matters training Simulation 9/20/13 NA Site Summary

WIC training Simulation 9/30/13 NA Site Summary

NA
NA


Community Elective List presentations or project descriptions not already listed above, include project
descriptions and estimated hours
Include site summary and other
documentation as needed
Project / title (approx hours) Site Completed
The Community Kitchen Food Sampling TCK February
17
th
, 2014

Cooperative Extension Translations Cooperative Extension July 13
th
,
2014

OncoAliados Handout Creation OncoAliados July 13
th
,
2014



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Keene State College Dietetic Internship page 6 of 6
Internship Requirements: Food Service
Assignment: list topic Site Completed Documentation Required in Portfolio
Food Service Experience Questions Havenwood Heritage Heights 10/1 Questions and answers to all sections for
primary FS site
30-hour Alternative FS Comparison Essay Kurn Hattin Homes 10/28 2-3 page essay comparing FS sites, as
described in handbook
Food Service Meal Project: Havenwood Heritage Heights 10/16 Final Report: summary of event as
described in handbook.
Equipment Proposal: Havenwood Heritage Heights 10/5 Written proposal
Systems Analysis: Havenwood Heritage Heights 10/5 Report on systems analysis and
recommended improvements
Employee In-service: Havenwood Heritage Heights 10/15 Outline of in-service
Overall Food Service Evaluation Site Summary Primary Food Service site
Food Service Management Skills Form
added at 60 hours and upon completion
Professional Development Eval Form at 60
hours and upon completion.
Site Summary 2
nd
Food Service site
PDE form for 2
nd
Food Service site.
Intern self-evaluations using Skills and PDE
forms
Food service rubric completed by
internship staff


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Internship Requirements: Clinical
Assignment: list topic Site Completed Documentation Required in Portfolio
Case Study: Crohn's Disease Concord Hospital, Keddy Hall July 7
th
,
2014
Copy of PowerPoint slides and any
handouts, Case Study evaluations
Billing Assignment: Concord Hospital June 20
th
,
2014
Assignment write-up as described in
handbook
Formulary Assignment: Concord Hospital June 20
th
,
2014
Assignment write-up as described in
handbook
Clinical Packets: Summer 2013 At home August 2013 Completed clinical packets, corrected
based on classroom discussion
Overall Clinical Evaluation Site Summary
Clinical Task Checklist
Clinical Skills Evaluation Form at ~15, 35
days and upon completion
Professional Development Eval Form at
~15, 35 days and upon completion
Intern self-evaluations using Skills and PDE
forms


Internship Requirements: IS


Assignment: Project and Community Partner Completed Documentation Required in Portfolio
Independent Study Project

The Community Kitchen Program
Evaluation
3/2014 Independent Study evaluation form
completed by self, preceptor, DI staff.
Presentation or display materials.
Summary of research
Presentation / Display The Community Kitchen Program
Evaluation
July 7
th
,
2014
Grant Proposal July, 2014 Completed grant proposal

Keene State College Dietetic Internship page 8 of 6
Quarterly Advising Meetings THIS SECTION TO BE COMPLETED BY INTERNSHIP STAFF

Completed for each Advising Meeting
2
nd

November
3
rd
February
4th
April
5th
End of
Program
Documentation Required in Portfolio
Self Assessment * Intern completes: Internship Self Assessment Form
*(Intern will complete the ADA professional self
reflection and PDP sections 1 & 2 for their FINAL
advising meeting)
Internship Requirements Site Sheet Intern completes: Internship Requirements Site
Sheet
Site Summaries for all sites Intern completes: Site Summaries for each site
worked
Weekly paperwork Intern completes: Weekly timesheets and journals
Professional Evaluation Advisor completes: PDE Form
Community Evaluation Advisor completes: Community Skills Evaluation
Form
Portfolio Evaluation Advisor completes: Portfolio Evaluation Form

Advising Meeting Notes (initial):
November -

February -

April -

Final -