Nutrition Assistants and Degreed Nutritionists

California WIC Career Development Request Form-Career Development( & Dietetic Internships For California WIC Employees (1/2013)

The information you provide is confidential and will only be used by the Career Development Coordinator to assist you in identifying education options to advance your career including qualifying and applying for WIC dietetic internships. It will not be used in the application and consideration of a dietetic internship.

Complete and e-mail to: Nancy Nesa, MA, RD, California WIC Career Development Coordinator at [email protected]

NAME:______DATE______E-mail______Daytime Contact Phone #______WIC Agency Employer: ______Location (City & Zip code)______Hire Date ______Job Title______

GPA DEGREE & DATE NAME OF SCHOOL DATES AREA OF RANGE ATTENDED STUDY (check one)  2.4 or less  2.5-2.9  3.0-3.3  3.4 or greater  unknown  2.4 or less  2.5-2.9  3.0-3.3  3.4 or greater  unknown Postgraduate dietetic Description of class classes

CONFIDENTIAL Diversity & Language Data:  Male  Female Country of origin if not USA______Year you moved to USA______Language of Origin (other than English) ______Other Languages______

Ethnic background:  Caucasian  Hispanic or Latino  African American  Asian  American Indian or Alaskan Native  Other, indicate______

Age Group:  under 25  25-35  36-45  46-55  over 56

Ability to speak Spanish?  Few words-none  Conversational  Fluent 1 California WIC Career Development A. Complete this section if you have a bachelor’s or master’s degree from an accredited Didactic Program in Dietetics (DPD) and a Verification Statement (VS) that qualifies you for a dietetic internship.

 What college or university issued the Verification Statement?______Date DPD completed/VS issued______ Have you ever applied to any dietetic internship?  NO  YES, list name of internships and dates you applied______ When do you plan to apply for a dietetic internship? ______ What type of internships are you considering and indicate your 1st choice and if there is a 2nd choice? ______Distance Dietetic Internships ______Local Dis ______WIC-based DIs  Are there any reasons that may prevent you from applying to a dietetic internship (DI)?  NO  YES, please indicate the most important reasons.  Financial/Cost  Location of DI  Work Schedule  GPA/Grades  Length of DI  Family/Personal  Other, please explain______ What information would be helpful to you in applying for a dietetic internship?  Application assistance  Improving qualifications  DI Options 

B. Complete this section if you would like to obtain the educational requirements qualifying you for a dietetic internship to become a registered dietitian.

 Did you complete the degree program and all the DPD classes but don’t have a VS that qualifies you for a dietetic internship?  NO  YES, what is the reason you do not have a VS? ______ Do you have a degree in nutrition or another field?  NO  YES, what degree and major? ______ Are you currently taking classes?  NO, when do you plan to start? ______ YES, how many classes have you completed in nutrition/dietetics? ______When do you plan to complete the requirements? ______C. Other Career Development Information Please describe your career goals or interests and check off the box below indicating the type of information you are interested in receiving: ______

______ Distance/Online Classes  Local College Programs  Information on Masters Programs  Career Counseling  Dietetic Internship Options  Funding, scholarship, loans  other ______