Application forms forprospective DFT Trainers
(March 2016 start)
Please note - applications will only be accepted on this original form.
New trainer applicants – please complete both parts 1 and 2 plus the Equal Opportunities Monitoring and training practice description form.
Existing trainers – please complete part 1 only and the Equal Opportunities Monitoring and training practice description form.
September 2015
Health Education West Midlands Dental Foundation Training Scheme
Part 1
1.Name ………………………………… (1a) Is this a Joint Application (Y/N)
If Yes Name of joint applicant:
Proposed lead trainer ………………..
Type of application: DFT Trainer: ...... FD by Assessment Trainer: ......
2.Practice Address ………………………………….
.....…………………………......
……………………………………………………….
……………………………………………………….
Email Address: ......
Tel (with STD Code) Day: - ………………………………..
Evening: - …………………………
3.Please indicate LAT: - …………………………………….
Personal No: - ……………………….
National Insurance No: - …………………………………
GDC No: - …………..……………...
Pilot Type & Detail (if applicable): ………………………………………………….
4.Qualifications (with dates and School) …………………………………………………………………………………………………
5.Protection Society …………………………………...
6.Number of years in UK general dental practice ………………………………………………
7.How long have you worked in the present practice? …………………………………..
8.What is your status in the practice? Associate/Sole owner/Partner (please give details)/other………………………………………………………………………………
If you are an associate please also give the practice owners name......
Please give your performer/provider number......
9.Please confirm you achieve or exceed the minimum personal Superannuable figure of £20k for non-specialist GDS in the previous financial year (Y/N)………
Please give figure …………………………
Please confirm you personally undertake a minimum of 1000 UDA’s per year (Y/N) ……….
Please give number of UDA’s usually completed each year ………………
10(i).Have you been involved in a Foundation Training Scheme as a Trainer or a DF Trainee?
If so give details
……………………………………………………….………..………….
10(ii).Have you had a previous DFT practice visit? If so, when? ……………………………
11.Date of last PCT/LAT Visit ……………………………………. (If applicable)
Date of CQC Visit ………………………………………… (If applicable)
12.Please indicate all other dental appointments held since qualification
Present ……………………………………………………………………………………….
Previous………………………………………………………………………………………
13(i).Have you undertaken any bullying and harassment training? Please give details.
…………………………………………………………………………………………………
…………………………………………………………………………………………………
13(ii).What experiences have you of Equality and Diversity training?
Please give details.
……………………………………………………………………………………………..
14.If you have had any dispute with the General Dental Council or Health Education/LAT, please give details.
…………………………………………………………………………………………
15.Please indicate the staff in your practice.
Full time Part time (No of sessions)
Dentists ...... ……...... ………......
Partners ...... …………......
Other Providers/Performers ......
Hygienists ......
Dental Nurses ......
Receptionists ......
Others (please specify) ......
16.How many surgeries are there in the practice?
a) Fully equipped ……………………………………………………………………………..
b)Partly equipped …………………………………………………………………………….
17.a) Are there any aspects of dental care not provided in the practice? (Please specify)
……………………………………………………………..
b) Will an FD be provided with a wide variety of Oral Surgery experience during the training year? ......
18.Please indicate where the technical work required for your practice is undertaken.
Acrylic......
Crown & bridge......
Orthodontic......
Other......
19.Are there any restrictions on the type of patients accepted for treatment in your practice?
(Please specify)
…………………………………………………………………………………………………
20.Do patients in the practice have freedom to choose their own dentist?
…………………………………………………………………………………………………
21.Will the FD take over an existing group of patients? ………………………………………….
If not, how many new patients per week will be available to the FD?
………………………………….
How many days’ work per week will be available to the FD? ………………………………….
22.Will you be prepared to engage in a formal weekly discussion period during normal practice working hours?
………………………………………………………………………………………………….
23.Would you be willing to complete a term report on the FD’s progress?
……………………………………………………………………………………………….
24.When would you like a FD to commence?
………………………………………………….
25.Please show the sessions when you would be present in the practice and carrying out
clinical work at the same time as the FD
Monday / Tuesday / Wednesday / Thursday / Friday / Saturdayam
pm
26. Can you provide experienced clinical support within the dental practice at all times when a
Foundation Dentist would be working, even if you are not in the practice? (Y/N) ………..
I understand that if I am approved as a Trainer:-
(i)I will be required to employ my Foundation Dentist under the
Approved Trainer/Foundation Dental Practitioner Contract
(ii) I accept that the decision of the Selection Committee is final and is not
Subject to appeal
(iii)To comply with the Data Protection Act 1998, I consent to the data
contained in this application being processed for the purpose of FD recruitment and to my practice details being published on the Committee of Postgraduate Dental Deans & Directors’ (COPDEND) or West Midlands Deanery website.
(iv)I understand that HEWM is obliged to report any circumstances where patient safety is an issue
(v)I agree to inform HEWM of any Criminal Investigation or Conviction or Disciplinary, GDC or LAT Investigation or findings, as soon as you become aware of them.
(vi)I agree to disclose any potential conflict of interests with regards to the education and training of family and relatives as Foundation Dentists.
Signature...... Date......
Please complete the above form, self-assessment
document(if applicable) and equal opportunities, practice description forms and return to
the below address.
Mr Lee Baglin
Health Education West Midlands
Postgraduate Team
St Chad’s Court
213 Hagley Road
Edgbaston
Birmingham, B16 9RG
Part 2 Practice Self-Assessment (for new trainer applications only)
A self-assessment of your dental practice prior to a practice visit will help the visitors and interview panel gain an understanding of you and your practice.
Please complete and return the form below to the Postgraduate Team, together with your application form as soon as possible. A practice visit will then be arranged.
Applicant’s name
______
Practice Address: ______
______
Daytime Tel No: ______
1.Location
Where and in what sort of area is your practice situated?
2.Premises
What type and age of building is used for your practice?
On which floors are surgeries, reception and waiting areas?
Can you provide care for disabled patients?
How is parking organised for staff and patients?
Are there separate WCs for staff and patients?
Other than surgeries, reception and waiting areas what other rooms do you have in the
practice?
How do you maintain cleanliness and decoration in the practice?
3.Reception and Appointments
Describe your arrangements for reception and waiting areas.
How do you organise your appointment system?
How are dental emergencies dealt with, in and out of surgery hours?
Where are patient notes kept in your practice?
Do you have a system of recalling patients?
4.Record Keeping
How and when are patient medical histories taken and recorded?
How can the operator be identified from the dental records?
Is full charting of a patient's dentition undertaken at any time?
Are patients examined for their periodontal condition?
Are treatment plans ever recorded?
What protocol or rationale do you follow when taking, storing and assessing the quality of radiographs?
Do you use a computer in your practice? If so, for what?
5.Surgeries
How many fully equipped surgeries does the practice have?
Would one of these surgeries be available to a FD for five days a week?
Your own surgery
Describe your own surgery and its equipment?
Do you feel comfortable that it meets current standards of design, usage and equipment?
How is amalgam handled in your practice?
How are light cure units maintained?
Do you use hand, sonic or ultrasonic scalers?
Where are intra-oral radiographs taken and viewed?
How do you arrange for clean 3-in-1 syringe tips?
Do you have sets of instruments for: - If so how many?
Examinations ( )
Conservation( )
Endodontics( )
Minor Oral Surgery( )
Periodontal Therapy( )
Do you use aspirating syringes?
Do you have or use semi-adjustable articulators in your practice?
Where is your surgery in relation to the proposed FD surgery?
Where would you hold tutorials?
The Foundation Dentist’s Surgery
Is the proposed surgery complete and ready to be visited, or has it yet to be installed or re-equipped?
Describe the surgery and its equipment.
Do you feel comfortable that it meets current standards of design, usage and equipment?
Will the FD have hand, sonic or ultrasonic scalers?
Where, and with what equipment, will the FD take and view intra-oral radiographs?
How many handpieces of the various types will be available to the FD?
How will clean 3-in-1 syringe tips be provided?
Will this surgery have sets of instruments for: - If so how many?
Examinations( )
Conservation( )
Endodontics( )
Minor Oral Surgery( )
Periodontal Therapy( )
Rubber Dam( )
Will LA aspirating syringes be available?
Could the surgery be used by a left-handed operator?
6Infection control
How is infection control managed in your practice?
How do you comply with the updated H&S sharps guidance?
Are you confident that, even if an item of equipment fails, you can still provide a regime to current acceptable standards?
What, if any improvements are you planning to make to comply with HTM01-05?
7.Radiographic Facilities
Do you believe your practice conforms to current radiological usage guidelines?
Which staff in the practice takes radiographs?
Do you use an OPT machine? If so when?
8.Plant and Services
How is clean, dry compressed air provided to your surgeries?
What sort of suction system is used in the practice?
Do you feel these services are safe and reliable?
- Laboratory support
How is laboratory support provided in your practice?
10.Emergency Equipment
What equipment is available in the practice to help treat medical emergencies?
What systems do you have to ensure staff and equipment are up to date in the treatment of medical emergencies?
Do you provide treatment under any form of sedation or anaesthesia?
11.Library
Have you available any text books, journals or reference books in the practice?
What equipment is available for clinical photography?
12.Staffing and Administration
How will you provide chairside assistance for a FD?
What patient treatments are referred out of the practice and to whom?
Who is responsible for the administration of the practice?
Do you find the need for formal staff meetings?
How many of your staff are long term employees?
13.Health and Safety and Employment Requirements
Please indicate which of the following are available in the practice and, if appropriate, whether in date
Yes / No / In date / TBAEmployers’ Liability Certificate on display
Medical Defence Certificate
Annual GDC Certificate
CQC Certificate of registration
Details of contract with LAT
Toxic waste/Consignment notes
Performing Rights Licence and/or TV licence (if applicable)
Health & Safety policy
Contract of employment for staff
Radiation maintenance check
Radiological Local Rules on display
COSHH assessment undertaken
Portable electrical appliances tested
Staff immunisation record
Complaints procedure
Data Protection Act complied with
Pressure vessel certification
Accident book (RIDDOR)
Waste disposal certificate
Fire Regulations
BNF/DPF
Practice manual
First Aid kit
Mercury spill kit
14.Workload
What is your assessment of the number of patients your practice cares for and the number of dentists who provide that care?
Describe your practice contract details with the LAT within the nGDS.
Describe your personal contribution to fulfilling the requirements of this contract.
What has been your previous experience with Associates, Performers and FD’s?
15.Relationships
What are your views concerning working with a FD?
Would there be any constraints on the type of treatment your FD can undertake?
16.Future Plans
What changes are you planning, or expect to occur, in your practice in the next two years?
Please complete the above application form, equal opportunitiesform and practice details form below and return as soon as possible to:
Mr Lee Baglin
Health Education West Midlands
St Chad’s Court
213 Hagley Road
Edgbaston
Birmingham, B16 9RG
CONFIDENTIAL
Equal Opportunities Monitoring
Postgraduate Medical and Dental Education aims to promote equal opportunities for all those involved in its training programmes. In order for us to monitor the effectiveness of this policy, please complete the following section.
This information will be treated in the strictest confidence and will not be circulated to the members of the Appointments Committee.
Name: ______Gender: Male/Female (Delete as appropriate)
Date of birth: ___/___/___ (Day/month/year)
Nationality: - ______Second Nationality: - ______
(If applicable)
Country of birth: ______
Ethnic Origin
Please mark the box that you feel most accurately describes your ethnic origin or racial group.
White / PakistaniBlack – Caribbean / Bangladeshi
Black – African / Chinese
Black – Other / Any other ethnic group
Indian / Prefer not to say
I hereby declare that the information given here is true.
Signature: ______Date: ______
Completed application forms should be returned to:
Mr Lee Baglin
Health Education West Midlands
St Chad’s Court
213 Hagley Road
Edgbaston
Birmingham, B16 9RG
Thank you for taking the time to complete this form.
Any information that you provide will be treated in the strictest confidence.
Training practice details
Should the practice be approved, a short descriptive paragraph is required. This will be circulated to potential FDs; please ensure that this is a full and accurate description as the FD depends on this for an understanding of your practice. It should indicate any relevant details of the locality of the practice, the type of work undertaken, the surgery equipment, support staff and any special features, e.g. whether the surgery can be used by a left-handed operator.
Please complete the details below:
Trainer's Name:-......
Practice Address:-......
......
Postcode: -......
Telephone No (please indicate STD Code):-......
Directions to practice:
Practice description: (Note this will be available to Foundation Dentists if they wish to visit the practice prior to completion of the recruitment process)