DENTALFOUNDATION, THERAPIST FOUNDATION AND DENTAL CORE TRAINING

DFT/TFT/DCTEDUCATIONAL SUPERVISORAPPLICATION FORM2018 – 2019 / FORM - PART B
For all Educational Supervisors
This is not an application for employment
Name of applicant:
To be completed by: / Existing and newEducational Supervisors to the programmes
To be read in conjunction with: / Foundation& Dental Core Educational Supervisor Application Guidance 2018 – 2019(
How to submit: / Hard copies to be submitted by post using a tracked delivery service only. Please see Application Guidance for address. Please complete form on computer or handwrite clearly and legibly in block capitals.
DEADLINE FOR APPLICATIONS: / 5PM FRIDAY 24 NOVEMBER 2017
I AM SUBMITTING
Practice Application A
(please mark “X” to confirm) / Each individual Educational Supervisor must complete a separate form and submit alongside a PART A for the practice they will train in
Name of Training Practice
(a Separate PART B is required for eachEducational Supervisor)
Are you applying as a Foundation Dentist or Therapist or Dental CoreEducational Supervisor? / DENTIST / THERAPIST / DENTAL CORE (circle as appropriate)
Are you a current Educational Supervisor on our Foundation Dentist , Therapist or Dental Core Schemes (If yes, please specify which)

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I confirm that: / Please mark below “X” to confirm:
All information and documentation provided is accurate and up to date
I am not aware of any disciplinary proceedings or investigations by the NHS Area Team, DPD or GDC in relation to me or the practice
I accept that professional references will be requested from GDC and NHS Area Teams by Health Education England Thames Valley & Wessex Office
I accept that for a period of up to 6 months after being deemed unappointable in this process, I may be precluded from applying to other Health Education England Thames Valley and WessexLocal Office training programmes, such as Dental Foundation Training by Equivalence (DFTQ)
I will be available from 1 September 2018 in the practice to supervise a Foundation Dentist/Therapist/Dental Core Trainee
I intend to remain working the practice which is applying for a training place until August 2018
I understand that I will be required to attend all Health Education England Thames Valley and Wessex Local Office meeting as listed in the Educational Supervisor Application Guidance in the section ‘Dates for your Diary’
I understand that approval/selection as anEducational Supervisor does not guarantee me a place on the Health Education England Thames Valley and WessexLocal Office DFT Schemes
I accept that the decision of Health Education England Thames Valley and WessexLocal Office shall be final
I have submitted all necessary supporting evidence and paperwork as specified in 1.2 and 1.6
I have current Medical/Dental Defence society membership, and have provided a copy of my current membership certificate with this application
I understand that I am providing you with personal information and that this will be used in accordance with the Data Protection Act 1998. I confirm that I have read the following webpage ( that gives details of how this data will be used.
Print Educational Supervisor Name:
SIGNED: / DATE:

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PART 1 – Proposed Educational Supervisor

1.1 Educational Supervisor Details

Title:
First Name(s):
Last Name:
Practice Name:
Address Line 1:
Address Line 2:
Town:
County:
Post Code:
Practice Telephone Number:
Mobile number:
Email address:
GDC Number:
Date of GDC first registration:
NHS Performer Number
(Essential):

1.2 General Details

Do you have a certificate, diploma or masters degree in dental or medical education? / YES / NO / If NO are you on a training programme for Cert Med Ed: / YES / NO
If YES give name of programme and expected completion date:
Are you applying to be a sole/joint Educational Supervisor? / SOLE / JOINT If JOINT please give name of other applicant:
How many UDAs did you personally achieve by year ended 31 March 2016: / I agree to the practice providing the following information:
(mark “X” to confirm)
2016/2017End of Year Statement of Activity:
I understand that if I worked in another practice during this time I will have to provide additional information:
Are you or have you ever been the subject of disciplinary proceedings or investigations by the PCT, Area Team, DPD or GDC in relation to you or your practice?
(References will be sought by the Health Education England Thames Valley and Wessex Local Office) / YES / NO If YES please give details:

1.3.1Existing Educational Supervisors Career History- existingEducational Supervisors ONLY

(newEducational Supervisors go to 1.3.2)

Please give brief details of any new dental posts you have held since January 2017.

1.3.2New Educational Supervisors Career History– new Educational Supervisors ONLY

EXPERIENCE IN NHS PRIMARY DENTAL CARE / Dates
As a Principal / Contract Provider in present practice:
As a Performer in present practice:
As a Principal / Contract 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)
In a hospital/armed forces/other:
(please state all that apply)
Any other dental posts held:
Previous and Current Honorary Appointments:
(please list)
Current Membership of Professional Organisations and Societies:
(please list)
Appointments to Professional Bodies, Committees and commitment to the dental profession:
(please list)

1.4 –Indemnity

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

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1.5– Continuing Professional Development

Please state how many verifiable CPD hours you undertook from January to December 2016.

TOTAL VERIFIABLE CPD HOURS 2016:

Please list the postgraduate courses or other verifiable CPD you have attended from January 2017 to date. (You may be asked for copies of certificates for verification during your practice visit). PLEASE TOTAL YOUR HOURS.

Date / Course / Verifiable
CPD Hours
TOTAL VERIFIABLE CPD HOURS 2017:

1.6 – Documents I have provided with this application form

Document / Please tick or mark with “x”
Medical/Dental Defence Organisation Membership Certificate

Appendix 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 / (dd/mm/yyyy)
*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
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

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