Dental foundation training



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PART 3 ā€“ Ability to Deliver Curriculum



3.1


Please declare what percentage of your total practice income is derived from NHS work. (This should be the same as your declaration for business rates reimbursement.)





Have you made any changes/improvements to your practice in the last 12 months?

If yes, please give details.

YES / NO

Are there any restrictions on the type of NHS patients or treatments accepted by the practice? If yes, please outline:



YES / NO

What are your out-of-hours arrangements for NHS patients?





What are your out-of-hours arrangements for private patients?





Please estimate the number of patients in the practice





Please estimate the number of new NHS contracted patients per month you take on





TOTAL UDAs for the PRACTICE year ended 31 March 2011/31 October 2011


Total UDAs

Please provide a copy of End of Year Statement of Activity 31 March 2011 AND Year End VDP Report up to 31 July 2011, issued 31 October 2011 (if applicable)

Please list ALL TRAINEE dentists and therapists in the practice

Name

Job Title (DF1/Therapist)

Scheme


Will the FD fill an existing vacancy?


YES / NO

Will the FD be at one practice full time?


YES / NO If NO give details

If you are absent from the practice for any reason how will you ensure the trainee is supervised?







3.2 Trainee Timetable and Supervision Arrangements



Please complete one timetable per training post
Trainer 1 (name)...........................................................................................................................
Trainer 2 (name)...........................................................................................................................

(if applicable)

Trainer 3 (name)...........................................................................................................................

(if applicable)





Training Post 1

Monday

Tuesday

Wednesday

Thursday

*outside term time the trainee is expected to carry out clinical work

Friday

Saturday

AM

Start


















AM

Finish

















Initials of trainer present

















PM

Start


















PM

Finish

















Initials of trainer present



















Training Post 2 (if applicable)

Monday

Tuesday

Wednesday

Thursday

*outside term time the trainee is expected to carry out clinical work

Friday

Saturday

AM

Start


















AM

Finish

















Initials of trainer present

















PM

Start


















PM

Finish

















Initials of trainer present


















The FDā€™s surgery must be available for 35 hours every week (28 hours term time).
PART 4 ā€“ Proposed Trainer/s
You must complete a separate Part 4 for each proposed trainer
4.1 Trainer 1


Title





First Name





Last Name





GDC registered address

(if not practice address)




Postcode





Telephone Number





Mobile





Email



Date of Birth



GDC Registration Number





NHS Performer Number





Qualification Date





Qualification Achieved e.g. BDS



Dental School



Postgraduate Dental Qualifications with dates




Are you on a GDC Specialist List? If YES please state which one


YES / NO

Do you have a particular interest in a branch of dentistry? If yes please state which


YES / NO

Are you applying to be a sole/joint trainer?


SOLE / JOINT

Are you an existing trainer?


YES / NO

How many UDAs did you PERSONALLY achieve during the year ended 31 March 2011?


Please provide a copy of End of Year Statement of Activity 31 March 2011

Do you practise solely within the NHS Contract?


YES / NO


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