WIC Counseling Evaluation Form site/Faculty._ Piedmont Health WIC Please rate student perfotmlance on the following competencies using the rating system below: lemonstrates entry level competence for dietitians, works independently 2 = demonstrates entry level competence for dietitians, requires occasionally assistant forking toward entry level competence for dietitians, requires regular assistance joes not demonstrate entry level competence for dietitians, requires routine assistance and needs to improve knowledge base. Student: NO = Not Observed, NA = Not Applicable i aiseus, Counseling & Education Time Period US/i¢ — ayiys lab date date date date Student develops educational materials for individualtarget group nl > Student prepares for counseling/educational session (Gia pea vals pt eeuton is paberd — i 2 i) 3 8 Student ses appropriate verbal and nonverbal communication skills (stant introduces ef, sows | good listening skills, uses open and close-ended 3 a 3 Ss {question to explore patient responses) | student knows and applies ndamentals of counseling for dietary change (comet explains therapeutic de, ‘meal plans, appropriate serving sizes, and demonstrate | 5 3) 5 Knowledge of nttonl supplements and food consituents) Student concludes counseling/educaional session (ummary of information discussed, planned behavior a S 3 S changes reviewed, follow-up and referrals discussed if applicable) Comments: preceptor date preceptor date