DENTALFOUNDATION, THERAPIST FOUNDATION AND DENTAL CORE TRAINING

DFT/TFT/DCTTRAINERAPPLICATION FORM2015 – 2016 / FORM - PART B
For all Trainers
This is not an application for employment
Name of applicant:
To be completed by: / Existing and new trainers to the programmes
To be read in conjunction with: / Foundation& Dental Core Trainer Application Guidance 2015 – 2016(
How to submit: / Hard copies to be submitted by post using a tracked delivery service only. Please see Application Guidance for address. Please complete form on computer or handwrite clearly in block capitals.
DEADLINE FOR APPLICATIONS: / 5PM FRIDAY 21 NOVEMBER 2014
I AM SUBMITTING
Practice Application A
(please mark “X” to confirm) / Each individual trainer must complete a separate form and submit alongside a PART A for the practice they will train in
Name of Training Practice
(a Separate PART B is required for each trainer)
Are you applying as a Foundation Dentist or Therapist Trainer? / DENTIST / THERAPIST / DCT (circle as appropriate)
Are you a current trainer on our Foundation Dentist , Therapist or Dental Core Schemes (If yes, please specify which)

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I confirm that: / Please mark below “X” to confirm:
/ All information and documentation provided is accurate and up to date
/ I am not aware of any disciplinary proceedings or investigations by the NHS Area Team, DPD or GDC in relation to me or the practice
/ I accept that professional references will be requested from GDC and NHS Area Team by the Deanery
/ I will be available from 1 September 2014 in the practice to supervise a Foundation Dentist/Therapist/Dental Core Trainee
/ I intend to remain working the practice which is applying for a training place until September 2014
/ I understand that I will be required to attend all Deanery meeting as listed in the Trainer Application Guidance in the section ‘Dates for your Diary’
/ I understand that approval/selection as a trainer does not guarantee me a place on the Health Education Thames Valley and Wessex DFT Schemes
/ I accept that the decision of Health Education Thames Valley and Wessex shall be final
/ I have submitted all necessary supporting evidence and paperwork as specified in 1.2
/ I have current Medical/Dental Defence society membership, and have provided a copy of my current membership certificate, and a copy of my up to date Personal Development Plan with this application
/ I understand that I am providing you with personal information and that this will be used in accordance with the Data Protection Act 1998. I confirm that I have read the following webpage ( that gives details of how this data will be used.
Trainer applicant name:
GDC Number: / Date of first registration:
Practice Name:
Practice Address
Address Line 1:
Address Line 2:
Town:
County:
Post Code:
Telephone Number: / Email Address:
SIGNED: / Name:
Date:

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PART 1 – Proposed Trainer

1.1 Personal Details

Title
First Name
Last Name
Telephone Number
Mobile number
Email address

1.2 General Details

NHS Performer Number
(Essential)
Do you have a certificate, diploma or masters degree in dental or medical education? / YES / NO / If NO are you on a training programme for Cert Med Ed: / YES / NO
If YES give name of programme and expected completion date:
Are you applying to be a sole/joint trainer? / SOLE / JOINT If JOINT please give name of other applicant:
How many UDAs did you personally achieve by year ended 31 March 2014: / I agree to the practice providing the following information:
(mark “X” to confirm)
2013/2014 End of Year Statement of Activity:
Vital Signs At a Glance Reports (covering April 2013 to March 2014:
I understand that if I worked in another practice during this time I will have to provide additional information:
Are you or have you ever been the subject of disciplinary proceedings or investigations by the PCT, Area Team, DPD or GDC in relation to you or your practice?
(References will be sought by the Deanery) / YES / NO If YES please give details:

1.3.1Existing Trainers Career History- existing Trainers ONLY

(new trainers go to 1.3.2)

Please give brief details of any new dental posts you have held since December 2012.

1.3.2New Trainers Career History– new Trainers ONLY

EXPERIENCE IN NHS PRIMARY DENTAL CARE / Dates
As a Principal / Contract Provider in present practice:
As a Performer in present practice:
As a Principal / Contract Provider elsewhere:
As a Performer elsewhere:
As an Associate / Assistant:
As an Associate / Assistant:
As a Salaried Primary Dental Care Practitioner / Performer:
As a Foundation Dentist/Vocational Dental: Practitioner (please give name/year of scheme)
In a hospital/armed forces/other:
(please state all that apply)
Any other dental posts held:
Previous and Current Honorary Appointments:
(please list)
Current Membership of Professional Organisations and Societies:
(please list)
Appointments to Professional Bodies, Committees and commitment to the dental profession:
(please list)

1.4 – Personal Development and Indemnity

Have you submitted annual returns to the GDC that comply with the minimum CPD requirements during the last 5 years (250 hours in total, 75 of which verifiable): / YES / NO
I have provided a copy of an up to date PDP with this application

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1.5– Continuing Professional Development

Please state how many verifiable CPD hours you undertook from January to December 2013.

TOTAL VERIFIABLE CPD HOURS 2013:

Please list the postgraduate courses or other verifiable CPD you have attended from January 2014 to date. (You may be asked for copies of certificates for verification during your practice visit). PLEASE TOTAL YOUR HOURS.

Date / Course / Verifiable
CPD Hours
TOTAL VERIFIABLE CPD HOURS 2014:

1.6 – Documents I have provided with this application form

Document / Please tick or mark with “x”
Up to date PDP
Medical/Dental Defence Organistaion Membership Certificate
Log of Trainer Sessions Attended at Deanery Organised Events (existing and current trainers only)

Appendix 1 – Monitoring Information

This section of the application form will be detached from your application form and will be used for monitoring purposes only.

NHS Organisations recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community.

*Date of Birth / (dd/mm/yyyy)
*Gender / Male Female I do not wish to disclose this

Race relations (Amendment) Act 2000

* I would describe my ethnic origin as:
Asian or Asian British
Bangladeshi
Indian
Pakistani
Any other Asian background
Black or Black British
African
Caribbean
Any other Black background / Mixed
White & Asian
White & Black African
White & Black Caribbean
Any other mixed background
White
British
Irish
Any other White background / Other Ethnic Group
Chinese
Any other ethnic group
I do not wish to disclose this

Employment Equality Regulations 2003

* Please select the option which best describes your sexuality
Lesbian
Gay
Bisexual / Heterosexual
I do not wish to disclose this
* Please indicate your religion or belief
Atheism
Buddhism
Christianity
Islam / Jainism
Sikhism
Other / Judaism
Hinduism
I do not wish to disclose this

Disability Discrimination Act 1995

The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you tell us that you have a disability we can make reasonable adjustments to where you work and your work arrangements and at interview.

* Do you consider yourself to have a disability? / Yes I do not wish to disclose this
No
Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.
Physical Impairment Learning Disability/Difficulty
Sensory Impairment Long-standing illness
Mental Health Condition Other

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