BUSINESS SERVICES ORGANISATONCPDA (Revised April 2017)

2 FRANKLIN STREET

BELFAST

BT2 8DQ

CERTIFICATE OF ATTENDANCE/APPLICATION FOR

CONTINUING PROFESSIONAL DEVELOPMENT ALLOWANCE

(See notes for completion overleaf)

PART 1 - PARTICULARS OF DENTIST (Please complete this section in BLOCK CAPITALS)

Surname ______MrMrsMissDrOther

Other Names (infull) ______DS No.GDC No.

Practice Address ______Home Address ______

______

______

Post Code ______

Are you claiming on behalf of an Assistant?YES NO

If yes Assistant’s Name ______GDC No.

PART 2 - PARTICULARS OF COURSE

Name of Centre (Venue)/ On-line provider:-______

Title of Course:-______

Date of Course:- ______Course Organiser :-

Length of Course:- from ______To ______No. of Hours ______

PART 3 - CERTIFICATE OF ATTENDANCE

I certify that the dentist attended the course and was present for _____ sessions

Signature ______Date ______

Designation ______

(Course Tutor/Course Organiser)

PART 4 - CLAIM

The total percentage of my/my Assistant’s* gross dental earnings attributable to work in the General Dental Service during the last complete financial year was: - ____ %

No. of sessions claimed =______Total =£ ______

Percentage Abatement** = £ ______

CPDA claimed = £ ______

* Delete as necessary.

PART 5 – DECLARATION

I declare that the information I have provided on this form is correct and complete and I understand that if it is not action may betaken against me.

Signature:- ______Date:- ______

For BSO use only.

Date received: - ______

Entered into system by: - ______Date: - ______

Verified By: - ______Date: - ______

NOTES FOR COMPLETION OF CLAIM FORM CPDA

1. Time limit for submission of Claim:-

A claim for CPD Allowance should be made within 6 months of completion of the approved postgraduate course.

2. Continuing Professional Development Allowance:-

The allowances payable for attendance at approved continuing professional development courses are shown inDetermination VII paragraph 4(3) of the Statement of Dental Remuneration. The amount claimed and abatement, if any, should be entered at Part 4 of the claim form. An allowance is not payable for a course thatis less than1 hour. A maximum of 6 approved sessions of more than 2 hours and up to 3 ½ hours, orequivalent, are payable in any financial year.

3. Completion of CPDA Claim form:-

Please make sure that ALL parts of the claim form are complete, failure to do so will mean the form beingreturned for completion resulting in a delay in the payment process. The completed claim form should bereturned to the Business Services Organisation or, if it has not been signed at Part 3, the Northern Ireland Medical & Dental Training Agency, Beechill House, 42Beechill Road, Belfast BT8 7RL.

A dentist attending a course which has not been organised by Northern Ireland Medical & Dental Training Agency shall have to seek CPDA approval from the Course Organiser. CPDA claims that have NOT BEEN APPROVED will not be processed for payment.

4. Assistants and Dental Foundation Trainees claiming CPDA:-

Assistants andDental Foundation Trainees should insure that their Principal completes theCPDA claim form on their behalf.