2016/2017
Dental Foundation Training: Application Form
Please complete this form electronically and submit as a word file. Please save your file with your surname and initial in the document title. Forms in other formats will be rejected and returned.
Please tick the boxes that apply to this application and then complete the application form.
☒ The practice is within the LDET area. I am applying for ☐ March 2016 OR ☐ September 2016
☐ The practice is within the HEKSS area
☐ I am applying as a sole trainer
☐ I am applying as a joint trainer. If this is a joint application, please name your co-applicant
Click here to enter text.
1.Name Of Applicant(s)Your full name as it appears on the GDC register / Click here to enter text.
2.Qualifications with dates
Your qualifications / Click here to enter text.
3.Contact Details
Name and address of the potential training practice
Practice website address (if applicable)
Is your practice part of a Dental Corporate?
Your preferred e-mail address
Day, evening, mobile telephone numbers
Contact name & address of your dental contract lead at NHS England / Click here to enter text.
Click here to enter text.
☐Yes Name Click here to enter text.
☐No
Click here to enter text.
Click here to enter text.
Click here to enter text.
4.Status
What is your status within the practice?
What is your Provider / Performer number
If you are a Partner, what is/are the name(s) of your other partner(s)
If you are a Partner, how long have owned a share of the practice?
If you are a Partner, have your other Partner(s) given their consent to this application?
If you are applying as an Associate(s), when did you start working at this practice under the present owner (month and year required)? / ☐Associate ☐Principal /Partner
Click here to enter text.
Click here to enter text.
Click here to enter text.
☐Yes ☐No
Please note that if you answer ‘No’ then your application will stall pending further information.
Click here to enter text.
Associate applicants only
If you are applying as an Associate, in which areas do you have some influence and control? / ☐Stock ordering ☐ Appointment scheduling
☐Staff selection ☐ Financial management
5.Professional status
Please summarise your other current role(s) and membership of professional organisations.
What other professional appointments have you previously held? / Click here to enter text.
Click here to enter text.
6.Indemnity
Please enter the name of your indemnity provider? / Click here to enter text.
7.Qualifications and Training
Please summarise any educational and/or training qualifications you currently possess.
Please provide brief details of any other postgraduate qualifications that you feel are relevant to this application. Please also provide details of any courses / studies that you are presently undertaking. / Click here to enter text.
Click here to enter text.
8.Experience of DFT / GDP experience
How many years’ experience do you have in general dental practice?
Please outline your previous experience of DFT. (If you are a new applicant, please check the new applicant box and go to the next question).
If you have been a trainee yourself, please state when and with what deanery? / Click here to enter text.
☐None as I am a new applicant
Click here to enter text.
Click here to enter text.
9.Applications to other deaneries
Have you or anyone else from your practice applied to be a trainer in any other deanery for this year?
If you have more than one practice in London and/or Kent, Surrey or Sussex, has anyone else from any of your other practices applied to be a trainer in London or KSS, or is anyone else already a trainer from one of your other practices. / ☐Yes ☐No If you have answered yes, please give the name of the person and the deanery to which they have applied.
Click here to enter text.
☐Yes ☐No If you have answered yes, please give details including the name(s) of the other applicants and the practice(s) in which they work.
Click here to enter text.
10.Working hours
a) Please enter what hours you intend your trainee to work to fulfil contractual requirements. Please use a 24 clock to indicate the times.
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
b) What are your normal working hours in this practice?
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
c) For joint applications only
What are the normal working hours in this practice of your co-applicant?
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Please provide the name(s) and qualifications of the dentist(s) from whom your trainee may seek advice in your and, if applicable, your joint trainer’s absence from the practice.
Click here to enter text.
In the table below and using their initials, please indicate when they are normally in attendance.
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
If you are a sole applicant, what arrangements do you plan to make to ensure your trainee has access to appropriate advice and guidance should the need arise?
Click here to enter text.
11.Compliance and Regulation
Are you currently or have you in the past 5 years been the subject of a GDC investigation?
Have you been under any investigation by NHS England in relation to your GDS contract during the last 5 years?
What was the outcome of your most recent CQC visit
What was the date of your most recent NHS practice inspection (if you are in KSS) or LDET practice inspection (if you are in London)? / ☐Yes ☐No
If you have answered yes, please provide brief details, including the date(s) of the investigation and the findings
Click here to enter text.
☐Yes ☐No
If you have answered yes, please provide brief details, including the date(s) of the investigation and the findings
Click here to enter text.
☐Totally compliant ☐Partially compliant
If partially compliant, please outline areas designated for improvement?
Click here to enter a date.
12.References
Please provide the names, job title, address, e-mail and contact telephone number of two dental professional referees
Please note that current LDET or HEKSS employees including Patch Associate Deans (in London) and Training Programme Directors (in HEKSS) cannot be nominated as referees as this may create a conflict of interest. / 1. Click here to enter text.
2. Click here to enter text.
13.Attachments
I am attaching the following additional supporting documents (as one individual pdf file for each) for each application.
If your application is part of a joint application and your joint applicant his submitting the information, then please tick this box ☐ and go to part 14.
☐ The most recent vital signs report for the intended training practice.
☐ The most recent BSA end of year complete statement of activity report for the last contracting year for the intended training practice (including FD activity – if applicable)
☐ A summary of my verifiable CPD hours for the last 5 years
☐ I attach the NHS practice inspection report (within three years) ☐ Not available
14.Declaration
By completing this section and checking the boxes, I understand that I am verifying the information given in this application form.
☐ I confirm that this form is an accurate representation of the facts as I believe them to be at the time of completion.
☐ I understand that any false representations made on this form will disqualify me from the trainer recruitment process.
☐ I agree to a practice inspection being undertaken and will make myself available for this.
☐ I give consent for LDET/HEKSS to take up references which may include the GDC, other deaneries /LETBs where relevant and the named referees.
☐ I also consent for LDET/HEKSS to approach NHS England to seek information on any contract breaches, remedial notices, complaints, and/or investigations which may adversely impact the suitability of the practice as a training practice.
☐ I confirm that I am/we are registered on e-wisdom (if you are applying from LDET) or DEBS (if applying from HEKSS).
☐ I understand that if I am appointed as a trainer, I shall comply with LDET/HEKSS policy and procedures under the nationally agreed Trainer/DFT contract.
15.Sign Off
Please check your application form carefully and ensure that all relevant sections have been completed.
☐ I have rechecked the form and now wish to submit it as my formal application to LDET/HEKSS.
Please enter your name again to verify the contents of your application.
Click here to enter text.
If you have any other comments that are relevant to your application, please make a note below
Click here to enter text.
Thank you for your application.
Application