DENTAL THERAPIST FOUNDATION TRAINING

TFT TRAINING PRACTICE APPLICATION FORM2013 – 2014 / FORM - PART B1
For Existing Trainers on the Programme
This is not an application for employment
Name of applicant: /
To be completed by: / Existing trainers on the programme
To be read in conjunction with: / Dental Therapist Foundation Training: Trainer Handbook
How to submit: / Please send your completed form by Recorded Delivery to
Angela Evans, NHS South of England, Dental Office, The Triangle, Roosevelt Drive, Headington, Oxford OX3 7XP
DEADLINE FOR APPLICATIONS: / 5PM FRIDAY 12 APRIL 2013
I AM SUBMITTING
Trainer Application B
(please tick 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) /

Page 1 of 6

I confirm that:
All information and documentation provided is accurate and up to date /
I am not aware of any criminal, civil or disciplinary proceedings or investigations by the PCT, DPD or GDC in relation to me or the practice /
I accept that professional references will be requested from GDC and the PCT by the Deanery /
I will be available from 1 September 2013 in the practice to supervise a Foundation Dental Therapist /
I intend to remain working the practice which is applying for a training place until August 2014 /
I understand that I will be required to be available for 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 Oxford & Wessex Deaneries TFT Scheme /
I accept that the decision of NHS South of England 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 an 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 attached document ( 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: /

Page 1 of 6

PART 1 – Proposed Trainer

1.1 Personal Details

As an existing trainer, you only need to complete the person details section if your details have changed in the last 12 months.

Title /
First Name /
Last Name /
Telephone Number /
Mobile number /
Email address /

1.2 General Details

NHS Performer Number /
Do you have a certificate, diploma or masters degree in dental or medical education? / Please selectNOYES / If NO are you on a training programme for Cert Med Ed: / Please selectNOYES
If YES give name of programme: /
Are you applying to be a sole/joint trainer? / Please selectSOLEJOINT If JOINT please give name of other applicant:

How many UDAs did you personally achieve by year ended 31 March 2012: / / I agree to the practice providing the following information:
End of Year Statement of Activity 31 March 2012 /
Existing Year End FD Report up to 31 July 2012, issued 31 October 2012 /
Annual Vital Signs /
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, DPD or GDC in relation to you or your practice?
(References will be sought by the Deanery) / Please selectNOYES If yes please give details:

1.3 Career History

Please give brief details of any new dental posts you have held since December 2011. /

Page 1 of 6

1.4 – Continuing Professional Development

Please state how many verifiable CPD hours you undertook from January to December 2011.

TOTAL VERIFIABLE CPD HOURS 2011: /

Please list the postgraduate courses or other verifiable CPD you have attended from January 2012 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 2012: /

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

Page 1 of 6