Request Form for Affiliation Agreement

1. Academic Institution Represented: *This question is required.

2. Your Name (First and Last): *This question is required.

3. Institutional Title/Role: *This question is required.

4. Email: *This question is required.

5. Phone: *This question is required.

6. What county(ies), or specific Tennessee Department of Health location(s), are you looking to have dietetic placements with? *This question is required.

7. Approximately how many students per year do you expect to seek dietetic placements with the Tennessee Department of Health? *This question is required.

8. Approximately how long would dietetic placements need to be (e.g., # of hours, weeks, months)? *This question is required.

9. Has your institution previously had an academic affiliation agreement for dietetics with the Tennessee Department of Health? *This question is required.

Request Form for Affiliation Agreement - Dietetics