Health Department/WIC Screening and Assessment Evaluation Form Student:_ Soy j Site/Faculty:_ Piedmont Heady WC Please rate student performance on the following competencies using the rating system below, 3 = demonstrates entry level competence for dietitians, works independently demonstrates entry level competence for dietitians, requires occasionally assistant working toward entry level competence for dietitians, requires regular assistance 0 = does not demonstrate entry level competence for dictitians, requires routine assistance and needs to improve knowledge base. NO = Not Observed, NA = Not Applicable Nutrition Screening & Assessment Biselis —_sjnpBime Period). yroris date date date date Student performs screening of eliens for nutrition | 4) a 3 s and health status and documents results | aes ae a 3 Student efficiently locates pertinent information ‘from client's records ‘Student includes all nutritionally relevant a a S as) information inthe nutritional assessment ‘Student interviews client for nutrition related data | ‘on activity level, and for cultural, economic, and | NLO 2 3 3 demographic factors using appropriate interviewing techniques. ‘Student understands and evaluates anthropometric Q a 3 3 data relevant to clients needs, Comments: 1_Skae, HEE Feqistened Okeh Naa. rd Em gyanis: gt Sine Sin the ‘paket. preceptor preceptor date preceptor date