Dental foundation training



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PART 4 – Proposed Trainer/s



4.2 Trainer 1 Career History


EXPERIENCE IN NHS PRIMARY DENTAL CARE

Dates


As a Principal / Provider in present practice





As a Performer in present practice





As a Principal / Provider elsewhere





As a Performer elsewhere





As an Associate / Assistant





As an Associate / Assistant





As a Salaried Primary Dental Care Practitioner Performer





As a Foundation Dentist/Vocational Dental Practitioner (please give name/year of scheme)





ANY OTHER DENTAL POSTS HELD





In a hospital/armed forces/other

(please state all that apply)





Previous and Current Honorary Appointments

(please list)





Appointments on Professional Bodies and Committees

(please list)





Current Membership of Professional Organisations and Societies

(please list)







4.3 Trainer 1


To which Medical Dental Defence society do you belong?


Please supply a copy of current membership certificate



Have you submitted annual returns to the GDC that comply with the minimum CPD requirements during the last 5 years (250 hours in total, 75 of which verifiable)


YES / NO

Please provide details of CPD for 2011 only


See next page


PDP

Please provide a copy of an up to date PDP





4.4 – Trainer 1 CPD



Name .........................................................................................................................................
Please list the postgraduate courses or other verifiable CPD you have attended from January 2011 to date. You may use this form or substitute this with a copy of your own records. (You may be asked for copies of certificates for verification). PLEASE TOTAL YOUR HOURS.


Date

Course


Verifiable

CPD Hours





























































































































































































PLEASE TOTAL YOUR HOURS





4.5 – Trainer 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




* 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 information

 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


4.6 Trainer 1 REHABILITATION OF OFFENDERS ACT
The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions to employers after the rehabilitation period set by the Court has elapsed and the convictions become ‘spent’.

During the rehabilitation period, convictions are referred to as ‘unspent’ convictions and must be declared to employers.


Before you can be considered for appointment with the NHS we need to be satisfied about your character and suitability.
The NHS aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation or age. The NHS undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Please answer the following question:


* Have you any unspent criminal convictions or bindovers, or any cautions, warnings or reprimands?

 Yes  No

If yes, please give details


If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory disclosure from the Criminal Records Bureau. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.



4.7 Trainer 1 DECLARATION OF INTERESTS


If you are related to a director, or have a relationship with a director or employee of an appointing organisation, please state the relationship




PART 4 – Proposed Trainer/s
You must complete a separate Part 4 for each proposed trainer
4.1 Trainer 2 (if applicable)


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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