Application for Approval of a Trainee's Training Facilities



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Trainee's Training Facilities




This form is not required when facilities are certified as appropriate by a Diplomate.
Include translations into English for attached files if the original item is not written in English.

Name of Applicant




Email address




Name of Primary Premises




Address of Primary Premises




Signature of the Applicant




Date Application Submitted




By signing above, I certify that this is an accurate description of the facilities etc. available to me for clinical practice during my EVDC training programme. I also agree to report any major changes in facilities or equipment that may occur before my next training program review date.

By signing this form, the Diplomate certifies that s/he has seen the facilities etc. described by the applicant, and that they are as described in this document.



Name of Diplomate




Email address




Signature of the Diplomate




Date Signed




For Revision of a Previous Application only:

Date of Previous Application




Signature of the Diplomate




Description of additions to or changes made since the last application:

Description of the Facilities


Photographic images are required. They are to be submitted as separate .jpg files uploaded to the Application document on DMS, named as described below.

Description of Primary Practice Premises:

Item


Brief description

Practice title and address







Public area (Waiting room, reception). Label images: Public area 1, 2 etc.




Consulting room(s). Label images: Consulting room 1, 2 etc.







Diagnostic and Pharmacy facilities (Radiology, Clinical Laboratory, Pharmacy. Label images: Public area 1, 2 etc.




Dental Operatory(s). Label images: Operatory 1, 2 etc.







Sterile surgery facilities. Label images: Surgery 1, 2 etc.







Library. Label images: Library 1, 2 etc.







Name and address of source of urgently required supplies


If you do not have a readily available local supplier you will need to hold significant stocks of materials.



If you use more than one premises for dental and oral surgical procedures, briefly describe the other facilities:


Practice title and address: Enter brief description:





Clinical records


Medical records and charts not originally written in English are to be submitted together with an English translation.

Item




General medical records. Enter either brief description or note that an example file is included in the DMS document.




Dental charts.

Indicate which types of dental chart are included as files in the DMS document.


Required: Dog, Cat, Rabbit, Rodent

Optional: Equine (required only if equine dental work is undertaken), Other Species:


Anaesthetic and Inpatient care charts.


Required: Anaesthetic chart

Optional: Inpatient care sheet, critical care chart. Indicate which are included in the document.






Client hand-outs: If not originally written in English, submit an English translation.

Client Hand-outs. List the topics included in the files uploaded as part of this DMS document:

List the topics included in the files uploaded as part of this DMS document:




Item

Brief description


Gas anaesthetic machine, including gas scavenging system.

Label images as Anesthesia Machine:

Anaesthetic monitoring and patient support equipment (heat pads, IV equipment).

Label images as Anesthesia Monitoring and Support:

Operatory Equipment: Storage facilities, work surfaces, operating table, operating lights, operator chairs, emergency lighting.

Label images as: Operatory equipment

Sterilization equipment: Autoclave, gas sterilization, chemical sterilization:

Label images as: Sterilization

Non-dental radiology unit (wet film or digital):

Label images as: Non-dental radiology.

Dental Equipment

Dental units, handpieces and burs


The recommended minimum quantity is given in brackets. Enter the quantity you have at each site and if not kept at the centre indicate what items you carry to the centre when working there. Include images named Dental units, hand-pieces and burs

Item

Minimum Required

Available at Primary Premises

Available at secondary premises or in mobile pack

Air driven dental system

1







High-speed air turbine handpieces

2







Low-speed air motors

2







Contra angle handpieces

2







Reduction gear contra angle

1







Polishing heads or handpieces

2







Electric dental hand engine

0







PUT NEXT SERIES OF ITEMS IN TABLE SIMILAR TO ABOVE

(0) (Assorted) FG burs: round, pear and fissure.

Provide a list of most frequently used types

702 TC 20 20 50

2 Round TC 5 5 5

4 Round TC 5 5 5

303 Diamond, coarse 10 10 5

Other 50 50 0

(Assorted) RA/CA burs

Provide a list of most frequently used types

Finishing stones 0 0 assorted

Finishing discs set set 0

Sizes ½ to 8 round * * many

(Assorted) HP burs

Provide a list of most frequently used types

Rabbit molar bur, diamond round end cylinder 0 0 1

8 Round, Ash surgical 6 6 10

702 Ash surgical 6 6 10

(1) Safety glasses

(Assorted) Disposable protective items (masks, gloves)


Clinical examination(New table, as above)


The recommended minimum quantity is given in brackets. Do not alter this column. Enter the quantity you have at this location and if not kept at the centre indicate what items you carry to the centre when working there. Include photographs named Examination.

Required Items Site1 Mobile kit

(1) Dental mirror

(4) Explorers/probes

(1) Magnification – 2.5 or 3 surgical loupes

(1) Lighting - oral or surgical

(1) Intraoral camera and films or digital camera


Dental radiography(New table, as above)


The recommended minimum quantity is given in brackets. Include photographs named Radiology.

Required Items Site1 Mobile kit

(1) X-ray viewing box


(required even if using digital system as cases may be referred with films)

(1) Dental X-ray unit

(Assorted) Dental radiographic films or sensors
Provide a list of available sizes/types
Note size 2 and size 4 equivalent sizes are required

(*) Processing facilities


Provide details

Digital system

Automatic or chair-side developer

(Assorted) Film clips

Radiographic film ID and storage

(Assorted) Radiographic safety equipment

Periodontics (New table, as above)


The recommended minimum quantity is given in brackets. Include photographs named Radiology.

Required Items Site1 Mobile kit

(1) Power scaler: ultrasonic or sonic


Provide details

(Assorted) Tips for scaler


Provide details

(Assorted) Hand scalers


Provide details

(Assorted) Hand curettes


Provide details

(2) Periosteal elevators

(Assorted) Sharpening stones & accessories

(*) Polishing paste

(*) Flour pumice or equivalent

(Assorted) Polishing cups

(0) Polishing brushes

(*) Plaque disclosing solution

(Assorted) Home care products
Provide details
(pastes, solutions, gels, sprays, treats, brushes, etc.)

Endodontics (New table, as above)


The recommended minimum quantity is given in brackets.

Required Items Site1 Mobile kit

(1) Endodontic organizer



Endodontic hand files

(*) Note that all sizes from 8 to 140 are required in


25-31 length, but they do not need to be of the same
type throughout the size range

25-31 mm ISO 8 to 10 (pathfinder) files

25-31 mm ISO 10 to 80 K- files or equivalent

25-31 mm ISO 10 to 80 K- reamers

25-31 mm ISO 15 to 80 H-files or equivalent

25-31 mm ISO 90 to 140 K-files

25-31 mm ISO 15 to 40 NiTi files (H and/or K)

(*) Note that all sizes from 15 to 120 are required in


veterinary lengths, but they do not need to be of the same
type throughout the size range. NOTE: Veterinary length
files may be ISO taper (16mm) or have double
length (32mm) working ends.

40-60 mm # 15 to 40 H- files

40-60 mm # 45 to 80 H- files

40-60 mm # 15 to 40 H- files NiTi

40-60 mm # 45 to 80 H- files NiTi

40-60 mm # 90 to 120 H- files

40-60 mm # 15 to 40 K-reamers

40-60 mm # 45 to 80 K-reamers



Endodontic engine systems

(0) Endodontic hand engine


Provide details if used

(0) Endodontic handpiece


Provide details if used

(0) Endodontic engine files


Provide details if used

Endodontic materials

(*) Gutta percha (GP) in ranges of sizes:

(Assorted) 25-31 mm ISO 15 to 140

(0) 25-31 mm Non-ISO sizes

Provide details if used

(Assorted) 40-60 mm in # 15 to 120


with taper matching the type of files used

(0) Heated system GP

Provide details if used

Required Items Site1 Mobile kit

(Assorted) Paper points in range of sizes:

(*) 25-31 mm ISO 15 to 140

(0) 25-31 mm Non-ISO sizes

(*) 40-60 mm in # 15 to 120

(*) Endodontic stops

(1) Endodontic ruler

(*) Irrigation needles – range of sizes


Provide details

(1 set) Spreaders (human length)

(1 set) Pluggers (human length)

(1 set) Pluggers (veterinary length)

(1 set) Spreaders (veterinary length)

(Assorted) Barbed broaches (human length)

(Assorted) Barbed broaches (veterinary length)

(*) Irrigant solutions


Provide details

(*) Chelating agent


Provide details

(Assorted) Spiral fillers –(human length)

(Assorted) Spiral fillers –(veterinary length)

(*) Sealer cements


Provide details

(*) Retrograde filling material


Provide details

(*) Calcium hydroxide powder and/or paste


Provide details

(*) Calcium hydroxide sealer/cement


Provide details

(0) MTA


(*) Mixing slab or mixing paper

(*) Assorted cement spatulas


Orthodontics: (New table, as above)


The recommended minimum quantity is given in brackets. Do not alter this column. Enter the quantity you have at this location and if not kept at the centre indicate what items you carry to the centre when working there.

Required Items Site1 Mobile kit

Impression materials –
see Restorative


Acrylic & temporary crown material –
see Restorative and Oral Surgery


Wire bending pliers and cutters –
see Oral Surgery

(*) Dental laboratory (orthodontic appliances)


Provide details

(0) Stone spatula

(0) Dental stone – type (III or IV)

(0) Dental vibrator

(*) Source of orthodontics requirements
Provide details if supplies are not available

(0) Orthodontic bonding agent

(0) Orthodontic brackets & buttons

(0) Orthodontic (spring) wires

(0) Power chains, elastic ligature, elastics

(0) Bracket application instrument

(0) Orthodontic bracket removal instrument

(0) Orthodontic pliers

(*) Model storage facilities

Insert photographs: Use a caption when appropriate.

Restorative: (New table, as above)


The recommended minimum quantity is given in brackets. Do not alter this column. Enter the quantity you have at this location and if not kept at the centre indicate what items you carry to the centre when working there.

Required Items Site1 Mobile kit

(*) Dental laboratory (prosthodontics)


Provide details

(1 set) Composite (light cure)

(Assorted) Plastic filling instruments

(1) Enamel etching agent

(1) Dentinal bonding agent

(Assorted) Composite finishing points, disks, etc.

Provide details

(1) Glass ionomer (chemical cured)


Required for emergency use if curing lights fail

(2) Curing lights

(1) Light curing safety glasses or shield

(Assorted) Finishing burs

(0) Other restorative materials

Resin modified glass ionomer

Compomer

Amalgam

Provide details



For amalgam, the necessary equipment needs to be listed:
Amalgamator/triturator or mortar/pestle
Amalgam well
Amalgam carrier or –pistol
Various hand instruments (condenser, carver, and burnisher)
Safety-waste box for amalgam waste

(0) Impressions trays – full jaw

(0) Impressions trays – for crown preparations

(1) Custom tray material

(*) Impression materials
Provide details

(*) Bite registration material


Can be a suitable impression material

(Assorted) Crown prep burs

(Assorted) Crown prep finishing burs

(0) Luting cement for crowns and bridges

(0) Retraction cord

(0) Cord packing instrument

(1) Haemostatic solution

Insert photographs: Use a caption when appropriate.

Oral Surgery(New table, as above)


The recommended minimum quantity is given in brackets. Do not alter this column. Enter the quantity you have at this location and if not kept at the centre indicate what items you carry to the centre when working there.

Required Items Site1 Mobile kit

(*) Surgical instrument kits


Provide details: i.e.
list contents of sets of surgical instruments
used for oral surgery, including drapes,
swabs etc.

(Assorted) Orthopaedic twisting wire

(1) Wire twisting forceps

(1) Wire bending pliers

(1) Wire cutters (small)

(Assorted) Acrylic burs

(1) Acrylic or temporary crown material

(1) Extraction forceps

(Assorted) Elevators - range of types and sizes
Provide details

(Assorted) Luxation instruments – range of sizes


Provide details

(Assorted) Periosteal elevators

(Assorted) Surgical blades

(Assorted) Suture materials


Provide details

(0) Grafting materials


Provide details

Insert photographs

Lagomorph and Rodent Dentistry (New table, as above)


The recommended minimum quantity is given in brackets.

Required Items Site1 Mobile kit

(Assorted) Range of cheek pouch dilators

(1) Mouth gag

(0) Set of cheek dilators

(0) HP bur guard

(Assorted) HP burs suitable for occlusal adjustment


Provide details.

(0) Fine grain diamond tooth rasp

(Assorted) Extraction instruments
Provide details

Cheek tooth extraction forceps

Cheek tooth luxator

Incisor tooth luxator


Equine Dentistry(New table, as above)


If you are involved in equine dentistry, please list your equine instruments, equipment, materials etc. providing details as appropriate

Required Items Site1 Mobile kit

(0) Mouth gag

(0) Viewing devices

(0) Tooth rasps

(0) Power rasp

(0) Hand instruments

(0) Extraction instruments

(0) Surgical instruments

(0) Anaesthetic equipment

(0) Other


Other species(New table, as above)


If you work on other species that require special instruments, equipment, etc., please list what you have available here, providing details as appropriate.

Required Items Site1 Mobile kit

(0) ?


Save this completed form as either a Word or .pdf file named LastName, FirstName Equipment and upload it to the DMS Equipment document.


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