Dental Foundation, Therapist Foundation and Dental Core Training

DENTAL FOUNDATION, THERAPIST FOUNDATION AND DENTAL CORE TRAINING

DFT/TFT/DCT TRAINING PRACTICE APPLICATION FORM 2018 – 2019 / FORM -PART A
For All Training Practices and Posts
Number of posts applied for:
DFT: / TFT: / DCT:
This is not an application for employment
Name of Practice:
To be completed by: / Employer (Practice Owner) / NHS Contract Provider
To be read in conjunction with: / Foundation & Dental Core Educational Supervisor Application Guidance 2018 – 2019

How to submit: / Single-sided 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 in block capitals in black ink.
DEADLINE FOR RECEIPT
OF APPLICATIONS: / 5PM FRIDAY 24 NOVEMBER 2017
I AM SUBMITTING
Practice Application (A)
(please mark with an X to confirm): / To be completed by Practice Owner / NHS Contract Provider
One application for each training practice (venue)
No. of Educational Supervisor Applications
(a Separate PART B is required for EACH Educational Supervisor): / No: / Each individual educational supervisor must complete a separate application form (PART B) and submit with this form
No. of Trainee Timetable Applications
(a Separate PART C is required for EACH training programme applied for): / A separate timetable must be submitted for Dental Foundation, Therapist Foundation, and Dental Core Training applications

STATEMENT (PART A)

TO BE COMPLETED BY NHS CONTRACT PROVIDER / EMPLOYER

I confirm that: / Mark “X” below to confirm:
/ I am the NHS Contract Provider at this address
/ I am the employer (practice owner). If not, please include details of employer
………………………………………………………………………………………..
/ 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 Team by the Health Education England Thames Valley and Wessex Local Office
/ I confirm my declaration for CQC compliance is truthful and accurate, and accept that the CQC will be notified if the practice has not yet received a practice inspection
/ I am able to offer the training place(s) applied for from 1 September 2018 for a period of twelve months
/ I agree to practices visit by Health Education Thames Valley (the Health Education England Thames Valley and Wessex Local Office)/ NHS Area Team, if deemed necessary, and understand that this may last between two and six hours
/ I understand that approval/selection as a training practice does not guarantee me a place on any Health Education England Thames Valley and Wessex Local Office training schemes
/ 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 Wessex Local Office training programmes, such as Dental Foundation Training by Equivalence (DFTQ)
/ I understand that if selected as a training practice I will be required to employ the Foundation Dentist under the approved National Educational Supervisor/Foundation Dentist contract, and Therapist and/or Dental Core Trainee under the approved regional Therapist/Core Training contract
/ This practice is not applying to any other Health Education England Thames Valley and Wessex Local Office schemes this year
/ I accept that the decision of Health Education Thames Valley and Wessex shall be final
/ I have provided practice visit reports and BSA DSD practice data as specified in 2.1 (2016/2017 End of Year Statement of Activity and Practice Information Leaflet).
/ 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.
/ I have provided a completed DFT self-assessment declaration form
NHS Contract Provider / Clinical Director Name:
GDC Registration Number: / Job Title:
Practice Name:
Practice Address
Address Line 1:
Address Line 2:
Town:
County: / Post Code:
Telephone Number: / Email Address:
SIGNED:
(Contract provider) / Name:
Date:

PART 1 – General Information

1.1 Practice – All applicants

Practice Website Address
(if applicable):
NHS Local Office:
(Tick box as appropriate) / Thames Valley
NHS England South (South Central)
Wessex
NHS England South (Wessex)
Hertfordshire & South Midlands
NHS England Midlands and East (Central Midlands)
NHS Provider Contract Holder Name:
NHS Provider Contract Number(s) (please provide all contracts at practice):
How many surgeries are there in your practice?: / How many dentists work in the practice?:
Is your practice owned by a Dental Body Corporate/NHS Trust?: / YES / NO If YES give brief details below: If NO go to 1.2
Name of Clinical Director: / GDC Number:
Email address:

1.2 Educational Supervisor Applicants 2018 – 2019 – All applicants

1.2.1 Dental Foundation Training

How many Educational Supervisors are you applying for in this post?
Educational Supervisor Applicant Names in this practice ONLY:
(Each Educational Supervisor must complete a separate PART B and submit with this application) / 1
2. (if applicable)
3. (if applicable)
4. (if applicable)

1.2.2 Therapist Foundation Training

How many Educational Supervisors are you applying for in this post?:
Educational Supervisor Applicant Names in this practice ONLY:
(Each Educational Supervisor must complete a separate PART B and submit with this application) / 1.
2. (if applicable)
3. (if applicable)
4. (if applicable)

1.2.3 Dental Core Training

PART 2 – Environment and Practice Facilities

2.1 Practice Systems and Governance – All applicants

Has the practice received a CQC visit? / YES / NO If YES provide date:
Is the practice currently CQC compliant: / YES / NO If NO please provide details:
(all applications will be checked online at
Is there a surgical extraction kit available for the trainee(s) to use? / YES / NO If NO, please explain why:
Are you already a training practice? / YES / NO
If YES, please answer the question below, otherwise skip to 2.2
Have there been any significant changes to the practice this year? Or are there any planned? (e.g. new: surgeries, staff changes, new IT systems, that will affect the trainee. Please also include any quality assurance awards.) / YES / NO If YES give brief details below:

2.2 The Surgery

Will each trainee work in their own surgery throughout the year? / YES / NO If NO give details below:

PART 3 – Ability to Deliver Curriculum

3.1 Training Capacity – All applicants

Please declare what percentage of the total practice income is derived from NHS work. (This should be the same as your declaration for business rates reimbursement.): / %
Are there any restrictions on the type of NHS patients or treatments accepted by the practice?: / YES / NO If YES give details below
Please estimate the number of patients in the practice: / Are you currently taking on new NHS patients?: / YES / NO
If YES, please state how many per month on average:
TOTAL UDAs achieved by the PRACTICE year ended 31 March 2017: / I have provided a copy of the following documents with this application (mark X to confirm):
2016/2017 End of Year Statement of Activity:
Practice Information Leaflet:
Is there capacity at this practice for the DFT and DCT trainee(s) full-time?
(part-time posts can only be considered in exceptional circumstances) / YES / NO If NO please give details:
What arrangements do you have to ensure the trainee is directly supervised at all times?