CONFIDENTIAL – Educational Supervisor Application

Foundation Training

Year 1

in

General Dental Practice

Please complete this form in black ink and return to:

Susan Tierney

Dental Foundation Year 1 Administrator

North Western Deanery

3rd Floor, 3 Piccadilly Place

Manchester

M1 3BN

EDUCATIONAL SUPERVISOR APPLICATION: CLOSING DATE 7th DECEMBER 2012

Application Form For DFT Year 1 Educational Supervisor

  1. Surname(caps)...... …......
  1. First Name(s).…………...... ………...... …......
  1. Title (Dr/Mr/Mrs/Miss/Ms etc) ......
  1. Practice Address.....……...... ….…......

...... ………..

...... ………..

...... ………..

Post Code ......

Tel...... Fax………………………………….…………..

  1. Internet Access at practice? YESNO

Access type: Broadband Dial Up Other

Practice Website:…………………………………………………………………………………..

Email address (compulsory) ......

  1. Primary Care Trust: ...... ………………………………………………………….

Contract No: ……...... …………....………………………...

  1. GDC No. ………………………………………
  1. Home Address:....……...... ….…......

......

......

Post Code: ......

HomeTel.: ...... Mobile: ...... ……......

  1. Indemnity Company (i.e. MDU/MPS):……………………………………………………………
  1. Current membership status:…………………………………………………………………
  1. Qualifications:...... ……......

(Dental School & Dates)

  1. Additional relevant qualifications (with dates): ……….……….………………………………

…….……………………………………………………………………….………………………….

………………….……………………………………………………………………………………..

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  1. Membership of Professional Organisations, Committees etc:

......

......

...... ……......

……………………………………………. ………………………………………………………

  1. Number of Years experience in General Dental Practice: ...... ………......

………………………………………………………………………………………………………..

…………………………………………………………………………………………………………

  1. Position In Practice:-

A) *(Practice Owner/Associated with Corporate Body/Partner/Performer)

*(FULL\PART-TIME)

B) Are you aware of any impending change to this status in the next 18 months?

*YES / NO*(Delete as applicable)

  1. Jobs since Qualification (Please give details of ALL Posts held since qualification):

......

......

......

......

…………………………………………………………………………………………………….

  1. Have you applied to be an Educational Supervisor before? YES/NO*

(*please delete as applicable)

  1. If you have been anEducational Supervisor before, please gives dates and scheme and Deanery:

......

......

………………………………………………………………………………………………………...

  1. When was your practice last inspected by the PCT?

………………………………………………………………………………………………………..

A)Was this a DRO or a Dental Adviser to the PCT inspection?

…………………………………………………………………………….

B) Do you have a copy of your report?YES/NO*

(Please delete as applicable)

  1. If you have applied to any other DFTscheme(s), please give full details:

(please note you may only be appointed to one Regional Scheme):

………………………………………………………………………………………………………

………………………………………………………………………………………………………...

  1. If you are currently an Educational Supervisor:-

Was your Practice visited between December 2011 and February 2012: YES/NO* (* please delete as appropriate)

Date of Visit……………………………………………………………………………………

Name of TPD(s)…………………………………………………………………………….

  1. Other currently posts held (e.g. clinical attachments, Dental Officer in salaried services etc) with dates::

......

......

.………………………………………………………………………………………………………..

  1. What are your special interests in dentistry?

………………………………………………………………………………………………………...

………………………………………………………………………………………………………...

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Practice Questionnaire

A: Practice Structure

  1. Please tick in the table below the sessions when you are normally present in the practice.

Monday / Tuesday / Wednesday / Thursday / Friday
AM
PM
  1. Please indicate when another dentist will be present.

Monday / Tuesday / Wednesday / Thursday / Friday
AM
PM
Name of Second Dentist:

B: Premises and Facilities

  1. Will you have a surgery free to accommodate the FD for five days per week?

………………………………………………………………………………………………………

C: Practice Organisation

  1. Are there any aspects of dental care which the practice is unable to provide?

......

......

......

YES / NO

D: Training / Education Arrangements

  1. How many days of work per week will be available to the Foundation Dentist?

…………………………………………………………………………………….

  1. Have you any special interests or skills that you feel would be useful to your Foundation Dentist?

......

......

......

  1. Have you any special contribution that you would be prepared to offer to the day release course?

......

......

......

  1. Would any of your colleagues in the practice be prepared to play a part in the training of the Foundation Dentist?

YES / NO*

*(delete as appropriate)

5.It is essential that Educational Supervisor applicants have attended the following training courses:-

Equality and Diversity Training – within the last 3 years (MANDATORY)

The Deanery provides courses inEquality and Diversity, this is an on line course. If you require E & D training please contact:

Please ensure that you provide your GDC number and email address for registration on this course.

Please indicate if you have attended Equality and Diversity Training within the last 3 years YES/NO*

*(delete as appropriate)

Date of training:…………………………………………………………………………………….

Course Organiser:………………………………………………………………….

  1. The UCLAN Facilitating Learning in Dental Practice course or equivalent educator’s course, (MANDATORY) evidence of completion or enrolment will be required. Details of the course can be found in the course section of the deanery website.The course will address developing the workplace as a learning environment; planning, preparing, designing and evaluating learning activities; assessment and management of learning and personal and professional development. Participants will gain skills in teaching and assessing learners across the interprofessional team and will be supported to develop as critically reflective teachers and practitioners. Contact UCLAN:
  1. Interviewing skills and Presentation technique, (Optional – limited places available) – Friday 18 January 2013, for further details and application form please contact:

Dental Foundation Training year 1

Information Sheet

The North Western Deanery has 5 Dental Foundation year 1 schemes and are based at Pennine (based at Oldham), Wythenshawe, Lancaster, North Manchester and Blackburn. Each scheme is organised by a Training Programme Director:-

David Read (Pennine Scheme)

Tel: 01204 573100

E-mail:

Arshid Hussain (North Manchester Scheme)

Tel: 0161627 5242

Email:

Carolyn Temple (Wythenshawe Scheme)

Tel: 01270 211171

Email:

Mark Ray (Blackburn Scheme)

Tel: 01204 705363

Email:

Kiaran Weil (Lancaster Scheme)

Tel: 01254 773512

Email:

Each Training Programme Director is supported by a secretary at each of the postgraduate centres.

A Dental Foundation Administrator based within the Dental Section of the North Western Deanery provides a centralised administrative service which includes the recruitment and selection process of Educational Supervisors:-

Susan Tierney

Tel: 0161 625 7661

Fax: 0161 625 7510

E-mail:

Schedule of DFT Events:

Date
/ Event
07.12.2012
/ Deadline for receipt of application forms
The Deanery will then contact you to arrange a practice inspection if you have not had one by our Deanery in the last year.
A pre-practice inspection form will be sent to you prior to the inspection, it is important that you complete it and return it to the Deanery at least two weeks before your visit date.
Mid Jan- Feb
/ Practice Inspections
Should your practice visit be successful, you will be invited to a formal competitive interview.
Feb 2012 - TBC / Trainer interview days
April 2013
/ Local allocation of foundation dentists to dental practices
June/July 2013
/ BDS results announced
July/August 2013
/ FDs start in practice

If you require any further information please contact Susan Tierney at

Or David Read, Associate Director of Dental Foundation Training at

Have you ever had an adverse finding from a PCT or GDC investigation?

Or have you ever been refused, or had conditions imposed on your professional indemnity?

If so please specify:-…………………………………………………………………………………………………………………………

I accept that the decision of the Selection Committee shall be final and not subject to appeal.

Signature...... Date ......

IMPORTANT!: PLEASE ALSO COMPLETE AND SIGN THE DATA PROTECTION DECLARATION OVERLEAF

DATA PROTECTION ACT, (1984) 1999


The North Western Deanery is registered with the Data Protection Registrar under the Terms and Conditions of the Data Protection Act updated 1999. The organisation is committed to upholding Eight Protection Principals of good information handling practice.

I understand that the information provided in the application form will be processed in accordance with the Data Protection Act. I understand that my details and practice information will be published as part of the list of approved Educational Supervisors in this Deanery on the Deanery’s website.

Where appropriate, information is shared with those who have a responsibility for the organisation, management and delivery of training, to help them execute their function in the planning and delivery of training for dental staff.

……………………………………………………….……………………………… SIGNED

………………………………………………………………….………………….. NAME (CAPITALS)

………………………………………………………… DATE

OFFICE COPY

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING BELOW AND

RETAINING A COPY:

I understand that if I am approved as anEducational Supervisor, I will be required to employ my FD as a Performer in Training under the approved Vocational Training in the G.D.S.

I understand that the Dean of Postgraduate Dental Education may seek references from the following Bodies:-

•PCT

•General Dental Council

I understand that a condition of my appointment as anEducational Supervisor is avisittomyPractice by representatives of the Dental Foundation Training Team and asubsequentinterview.

I understand that if I am appointed as anEducational Supervisor, I will be required to:-

(i)attend Training Courses

(ii)be liable for involvement in 14 educational sessions in connection with the Scheme as requested by the Training Programme Director

(iii)devote at least one hour of surgery time to a tutorial with my FD each week

(iv)work clinically in the same premises as the FD for at least six sessions each week

I confirm that the information provided herein is, to the best of my knowledge, correct and accept that the decision of the Selection Committee shall be final and not subject to appeal.

Signed:...... Date: ......

Equal Opportunities Monitoring Form

The North Western Deanery is committed to ensuring that no dentists in training receive unjustified less favourable treatment on the grounds of their age, colour, ethnic origin, nationality, religion/beliefs, sex, sexual orientation, disability or parental/carer responsibility.

Suitable VT applicants will be selected solely on the basis of merit. The Dental Section is monitoring its activities to ensure that its equal opportunities policy is effectively implemented.

Please answer all the questions below and return this form with your completed application form.

This information will be treated in strictest confidence. It will not be seen by the selection panel and will not be used in the selection process. It will not be available for any purpose other than present / future equal opportunities monitoring.

1. Gender

MaleFemaleTranssexual

2. Age

Please indicate your year of birth______

3. Marital Status

SingleMarried (first marriage)

Co-habitingRe-married

DivorcedSeparated

Widowed

4. Dependants

Do you look after or give support on a daily / weekly / monthly basis to either a family member, friend or neighbour belonging to one of the following groups:

  • a dependant child or young personYesNo
  • a person with a long-term physical or mental health problemYesNo
  • a dependant elderly person?YesNo

5. Religious affiliation

Do you have a religious belief?

YesNo

If yes, are you:

Roman CatholicPresbyterian

Church of EnglandMethodist

BaptistMuslim

HinduJewish

BuddhistSikh

Baha’iOther, please specify ______

6. Ethnicity

Please tick the appropriate box to indicate your ethnic origin and specify your nationality:

White

(British / Irish / Other White background)

Mixed

(White & Black Caribbean / White & Black African / White & Asian / Any other Mixed background)

Asian or Asian British

(Indian / Pakistani / Bangladeshi / Any other Asian background)

Other Ethnic Groups

Chinese

Any other ethnic group (please describe) ______

Not stated

7. Disability

In accordance with the Disability Discrimination Act 1995, a disability is defined as "a physical or mental impairment that has substantial and long term adverse effect on your ability to carry out normal day to day activities". Do you consider yourself to have a disability?

YesNo

If Yes please specify the nature of your disability and provide details of your specific requirements so that we can make any necessary reasonable adjustments or adaptations that will improve your access to our services, offer you a fair selection interview, make reasonable adjustments to working arrangements and/or ensure that you enjoy equal participation in working with us.

______

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