Foundation training for general dental practice application form for



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Year ……………………………………………………….

Name ……………………………………………………….

HEALTH EDUCATION KENT SURREY & SUSSEX

FOUNDATION TRAINING FOR GENERAL DENTAL PRACTICE

APPLICATION FORM FOR

TRAINER

For 2014/2015

It is important that you read the accompanying notes for applicants before completing this form

Please complete ALL sections and sign the declaration on Part 2; Page 7
Failure to answer all the questions may result in your application not being

Shortlisted State not applicable (N/A) where appropriate
When completing this form, please use black ink and BLOCK CAPITALS.

Please ensure that you attach the documents as listed in Part 2; Page 8. Your application will not be shortlisted if any available documents are missing



If this is a joint application please tick here and also use a Joint Application form

http://kssdeanery.org/dental

Strictly Confidential - for HEKSS use only Part 1; page 1

PART 1

Personal Details

1.

Title




Last name




First name







2.

Practice address including postcode




Home address including postcode


























































Tel. No.

Fax No.


E-mail:







Tel. No.

Mobile No.

E-mail:





3.

Qualifications (with dates)

Dental school







Area Team on whose performer list you are included
Performer number
Area Team in whose area the proposed practice is, if different

4.



GDC registration number Annual practising certificate 





Name of indemnity provider







5.

Are you currently part of a dental body corporate?

Yes  No



Experience in general dental practice (please give dates and locations)


As a practice owner in present practice
As a practice owner elsewhere
As an associate/assistant
Previous experience in hospitals/CDS/other dental services (please give dates and locations)
As a FDP (Foundation Dental Practitioner - trainee)

Name/year of scheme:









Strictly Confidential - for HEKSS use only Part 1; page 2



6.

Have you ever been, or applied to be, a Trainer in this or any other region?

If yes please state the year, the scheme and whether you were approved

Yes  No








Do you have a current application, or been appointed as a trainer in another region? Yes  No Please state region ____________

Please state whether the appointment was as a Sole or Joint Trainer _______________________






7.

Previous and current salaried dental appointments

Dates








8.

Previous and current honorary appointments (ie BDA, DPA etc)

Dates











9.

Appointments on professional bodies (ie LDC, BDA etc)

Dates












10.

Current membership of professional organisations








Strictly Confidential - for HEKSS use only Part 1; page 3



11
11a
11b

Are you undertaking postgraduate dental/other qualifications?  Yes  No

Please detail:

I am registered on the HEKSS Dental Education Booking  Yes  No

System (DEBS). www.kssdentaltraining.co.uk (This is mandatory for all applicants)

Have you completed the Trainer Education Module  Yes  No

If yes, please state date/month/year ……………………………………..

Have you completed the Mentoring Module  Yes  No

If yes, please state date/month/year ……………………………………..




12.

(a) In the last six years have you been subject to action or investigation by an Area Team in relation to the Dental Performers’ List? i.e. an action or investigation regarding your suitability to be included in the Area Team’s Dental Performers’ Lists

Yes  No If yes, please provide date and details __________________________________

________________________________________________________________________________

(b) In the last six years have you been subject to a complaint or investigation by the GDC?

Yes  No If yes, please provide date and details __________________________________

________________________________________________________________________________

(c) Do you have any outstanding issues after a CQC inspection or is the CQC taking any compliance action against your practice?

Yes  No If yes, please provide details _________________________________________



________________________________________________________________________________

Please see notes on references –Part 2, Page 7


FDP Information


13.

When is a vacancy for a FDP (trainee) likely to occur?

________________________




Will the FDP be










a) an additional dentist in the practice?

Yes 

No 




b) a replacement for a current dentist?

Yes 

No 




c) a follow-on FDP?

Yes 

No 




d) full-time in this practice?

Yes 

No 


Please specify actual times (use 24 hour clock) for questions 14 to 17.


14.

FDP’s working hours outside term time (35 hours for full-time FDP)




Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Am



















Pm



















Eve



















15.

Your regular availability at the training practice




Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Am



















Pm



















Eve


















16.


Strictly Confidential - for HEKSS use only Part 1; page 4

Where will you be at times you are unavailable for the FDP






Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Am



















Pm



















Eve






















17.

Dentist/s present in your absence, or, dentist whom the FDP may contact in your absence




Name

Year of qualification Qualifications




Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Am



















Pm



















Eve




















Practice Information


18a

In how many other practices do you have a financial interest?

_____________

List the other practices, the number of surgeries in each and enter days/times you attend these at 17 above.

18b

If you provide dental services at any other locations, please list these and enter days/times you attend these at 17 above

19.

In the intended training practice, how many fully functional surgeries are there?

______________

a) Location

 City

 Town

 Village

 Main road

 Side road

 Shopping centre

Residential

 Industrial

 Commercial

 Health centre

 Other (Specify): _____________________________

b) Design

 Purpose-built

Converted

 Single-storey

 Multi-storey

Wheelchair access

 Easy

 Difficult

 Impossible

Car-parking

Private

 Street

 Difficult




20.

Personnel




Intended training practice


Second practice

(if applicable)



Third practice

(if applicable)



Your status













Partners

F/T

……………………………………………………………………………...




(with names)

P/T


Other Performers

F/T

……………………………………………………………………………..

……………………………………………………………………………..

……………………………………………………………………………..

……………………………………………………………………………...


(with names)

PT


Dental nurses

(with names) *



F/T

……………………………………………………………………………..

……………………………………………………………………………..

……………………………………………………………………………..



P/T




Strictly Confidential - for HEKSS use only Part 1; page 5

Practice Manager/s




…………………………………………………………………………….

Other Clerical – please specify role

F/T

……………………………………………………………………………..



(with names)

P/T

Therapists/

Hygienists



F/T

……………………………………………………………………………...



(with names)

P/T

Technicians

F/T

……………………………………………………………………………..



(with names)

P/T

* Please state if Dental Nurses are registered or in training
Practising Information


21.

Detail, with reasons, any special training, interest or skills that you have which would be useful to your FDP






22.

The main practice contract:

a) covers mandatory services for all categories of patients Yes □ No □

b) is limited to certain patient groups:-

i) exempt and under 18’s only Yes □ No □

ii) under 18’s only Yes □ No □

iii)other – please detail Yes □ No □

c) covers some non-mandatory/additional (eg. Sedation, orthodontics Yes □ No □

or domicilaries) services – please detail



Practice Turnover


23.

Workload




Please estimate the total number of patients in the proposed FT practice

___________

How many patients are currently treated within GDS/PDS arrangements in the proposed FT practice?

___________



Please estimate the number of new NHS patient enquiries per month

___________

Estimate the proportion of your patients you personally treat within the NHS

___________%

Estimate the proportion of patients the practice treats within the NHS

___________%

Please estimate the likely number of patients immediately available to the FDP

___________




24.

Activity







What is your total practice UDA requirement for the year?

_____________




What percentage of practice UDA requirement was achieved in the last financial year?

_____________




How many UDA’s did you personally complete in the last financial year?

_____________




How many UDA’s do you expect to complete in the next financial year?

_____________

25. FOR EXISTING TRAINERS ONLY WHO ARE ATTENDING INTERVIEW


Sessions of DFT related activities attended for 2013/2014 Schemes (if applicable):
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