Dental foundation training



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DENTAL FOUNDATION TRAINING



DF1 TRAINING PRACTICE APPLICATION FORM

2012 – 2013
Part 1 – General Information

Part 2 – Environment and Practice Facilities

Part 3 – Ability to Deliver Curriculum

Part 4 – Proposed Trainer/s

Part 5 – Authorisation and Confirmation

To be read and completed in conjunction with the DF1 Trainer Handbook 2012 - 2013

ADDRESS FOR APPLICATIONS TO ARRIVE BY

5PM THURSDAY 22 DECEMBER
Please post or email (faxes cannot be accepted)

(Pages 21 and 22 will need to be signed and sent in by post prior to interview)

Scanned supporting documentation is acceptable

Miss Brenda Leach

Foundation Programme Co-ordinator

Dental School

Oxford Deanery

The Triangle

Roosevelt Drive

Headington



Oxford

OX3 7XP
Brenda.leach@oxforddeanery.nhs.uk


Tel: 01865 740652

Please complete electronically or in BLOCK CAPITALS



PART 1 – General Information


1.1 Practice



Practice Owner’s Name





Practice Name



Practice Manager’s Name





PCT Name





NHS Provider Contract Holder





NHS Provider Contract Number (information contained on practice stamp)




Practice Address





Postcode





Telephone Number





Practice Email



Website Address





Is your practice owned by a Dental Body Corporate/NHS Trust?


YES / NO

Name of Corporate Body/NHS Trust



Name of Clinical Director





Email







1.2 Trainer Applicants 2012 - 2013





Trainer Applicant 1





Trainer Applicant 2

(if applicable)



Trainer Applicant 3

(if applicable)





1.3 Training Post/s





How many training posts (trainees) are you applying for?






PART 2 – Environment and Practice Facilities


2.1 Practice Staff and Facilities

Please provide a current Practice Information Leaflet that complies with NHS requirements.




2.2 Practice Systems and Governance

Please provide both a copy of your CQC registration and action plan plus either





2.3 Trainee’s Surgery








Trainee 1

Trainee 2 (if applicable)

Size








Suitable for left/right handed dentist (essential)


YES / NO

YES / NO

Number of handpieces:








Air Rotas








Slow handpieces








Straight handpieces








Instruments – sufficient available?








Xray machine In surgery

YES / NO


YES / NO

Separate Xray room


YES / NO

YES / NO

Intraoral camera (essential)


YES / NO

YES / NO

Video camera (essential)


YES / NO


YES / NO

Practice library


YES / NO

YES / NO

Computerized patient records


YES / NO

YES / NO

Access to PC/internet for FT in surgery (essential)


YES / NO

YES / NO

Qualified dentist available to support trainee at all times


YES / NO

YES / NO


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