Weight Control Program Forms

If you have determined based on the Rules or by the simple guide, found here, that you are indeed operating a weight control program in North Carolina, the next step will be to secure a Reviewer as defined in 21 NCAC 17 .0201 (3), and submit the forms posted on this page.

1. Weight Control Program Contact Information Form – This is to be completed and signed by the Weight Control Program Director.

Contact InformationPDF

2. Additional Locations Form – This form only needs to be completed if there is more than one location.

Additonal LocationsPDF

3. Written Assessment Form – This form is to be completed by the Reviewer. Per 21 NCAC 17 .0201 (3) a “Reviewer means a person who is: (a) a licensed dietitian/nutritionist; (b) a dietitian/nutritionist licensed in another state that has licensure requirements that are at least as stringent as under G.S. 90, Article 25; or ( c) a dietitian registered by the Commission on Dietetic Registration of the ADA.”

Written Assessment FormPDF

4. Consultation Confirmation Form – Under the statute and Rule, each center must have consultation available from an LDN, RD or RD/LDN. This person may be the same person as the Reviewer, but they are not required to be.

Consultation ConfirmationPDF