DENTAL THERAPIST FOUNDATION TRAINING

DENTAL THERAPIST TRAINING PRACTICE APPLICATION FORM2013 – 2014 / FORM - PART A2
For New Training Practices
This is not an application for employment
Name of applicant: /
To be completed by: / Practice Owner / NHS Contract Provider
To be read in conjunction with: / Dental Therapist Foundation Training Scheme Handbook 2013/14
How to submit: / Please send your completed form by Recorded Delivery to
Angela Evans, NHS South of England, Dental Office, The Triangle, Roosevelt Drive, Headington, Oxford OX3 7XP
DEADLINE FOR APPLICATIONS: / 5PM FRIDAY 12 APRIL 2013
I AM SUBMITTING
Practice Application (A)
(please tick to confirm) / / To be completed by Practice Owner / NHS Contract Provider
One application for each training practice (venue)
No. of Trainer Applications
(a Separate PART B is required for EACH trainer) / / Each individual trainer must complete a separate application form (PART B) and submit with this form
(EXISTING trainers – B1
NEW and returning trainers – B2)

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STATEMENT (PART A)

TO BE COMPLETED BY NHS CONTRACT PROVIDER / EMPLOYER

I confirm that:
/ I am the NHS Contract Provider and Employer /
/ All information and documentation provided is accurate and up to date /
/ I am not aware of any disciplinary proceedings or investigations by the PCT, DPD or GDC in relation to me or the practice /
/ I accept that professional references will be requested from GDC and PCT by the Deanery /
/ I am able to offer the training place(s) applied for from the beginning of September 2013 for a period of twelve months /
/ I agree to a practice visit by the Deanery/PCT 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 the NHS South Central TFT Scheme /
/ I understand that if selected as a training practice I will be required to employ the Foundation Dental Therapist under the Deanery contract /
/ I accept that the decision of NHS South of England shall be final /
/ I have provided a practice information leaflet, practice visit reports and BSA DSD practice data as specified in 2.1, 2.2, 2.3 and 3.1. /
/ 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 attached document ( that gives details of how this data will be used. /
NHS Contract Provider / Clinical Director Name: /
GDC Number: / / Job Title: /
Practice Name: /
Practice Address
Address Line 1: /
Address Line 2: /
Town: /
County: /
Post Code: /
Telephone Number: / / Email Address: /

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PART 1 – General Information

1.1Practice

Practice Website Address
(if applicable) /
PCT Name /
NHS Provider Contract Holder Name /
NHS Provider Contract Number (information contained on practice stamp) /
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? / Please selectNOYES If YES give brief details below: If NO go to 1.2

Name of Clinical Director /
Email address /

1.2 Training Post(s)

How many trainees are you applying for in this practice? /

1.3 Trainer Applicants 2013 - 2014

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

PART 2 – Environment and Practice Facilities

2.1 Practice Systems and Governance

Are you registered with CQC? / Please selectNOYES If YES write Provider ID and Location Number below:
Provider ID: / / Location number: /
Have you had a PCT/DPA/CQC visit within the last 12 months? If so please send us your report and updated action. (This should be scanned and emailed or faxed).
PCT visit / Please selectNOYES / Report provided? / Please selectNOYES
DPA visit / Please selectNOYES / Report provided? / Please selectNOYES
CQC visit / Please selectNOYES / Report provided? / Please selectNOYES

2.2 Practice Staff and Facilities

I have provided a current Practice Information Leaflet that complies with NHS requirements. /

2.3 Practice Systems and Governance

I have provided a copy of our last PCT/DPA/DRS/CQC visit report and action plan. /

2.4 Trainee’s Surgery

Trainee 1 / Trainee 2 (if applicable)
Size / Please selectNOYES / Please selectNOYES
Suitable for left/right handed clinician (essential) / Please selectNOYES / Please selectNOYES
Instruments – sufficient available? / Please selectNOYES / Please selectNOYES
Xray machine In surgery / Please selectNOYES / Please selectNOYES
Separate Xray room / Please selectNOYES / Please selectNOYES
Intraoral camera (essential) / Please selectNOYES / Please selectNOYES
Video camera (essential) / Please selectNOYES / Please selectNOYES
Practice library / Please selectNOYES / Please selectNOYES
Computerized patient records / Please selectNOYES / Please selectNOYES
Access to PC/internet for TFT in surgery (essential) / Please selectNOYES / Please selectNOYES
Qualified dentist/dental therapist available to support trainee at all times / Please selectNOYES / Please selectNOYES
Are you accredited by the BDA Good Practice Scheme? / Please selectNOYES
Do you have any external quality assurance of your practice?(apart from CQC) / Please selectNOYES If YES give details below:

PART 3 – Ability to Deliver Curriculum

3.1Training Capacity

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? / Please selectNOYES If YES give details below:

Please estimate the number of patients in the practice: / / Are you currently taking on new NHS patients? / Please selectNOYES
If YES, please state how many per month on average:
TOTAL UDAs achieved by the PRACTICE year ended 31 March 2012: / / I have provided a copy of the following documents with this application:
End of Year Statement of Activity 31 March 2012 /
Annual Vital Signs /
Below please list ALL TRAINEE dentists and therapists in the practice currently
Name / Job title (DF1/Therapist) / Scheme
1. / / /
2. / / /
3. / / /
4. / / /
Will the Foundation Therapist be at this practice for the full 3 days a week?
(split posts can only be considered in exceptional circumstances) / Please selectNOYES If NO please give details:

What arrangements do you have to ensure the trainee is directly supervised at all times? /

3.2 Trainee Timetable and Supervision Arrangements

The TFT’s surgery must be available to the trainee for 24 hours every week. The trainee must work a maximum of 8 hours a day and no more than 3 days in each week as a TFT.

Training Post 1
First Trainer (name) /
Second Trainer (if joint) /
Monday / Tuesday / Wednesday / Thursday* / Friday / Saturday
Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer
AM
Start time / / / / / / / / / / / /
AM
Finish time / / / / / /
PM
Start time / / / / / / / / / / / /
PM
Finish time / / / / / / / Total weekly hours
Total daily hours / / / / / / /
Training Post 2 (if applicable)
First Trainer (name) /
Second Trainer (if joint) /
Monday / Tuesday / Wednesday / Thursday* / Friday / Saturday
Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer / Time / Initials of trainer
AM
Start time / / / / / / / / / / / /
AM
Finish time / / / / / /
PM
Start time / / / / / / / / / / / /
PM
Finish time / / / / / / / Total weekly hours
Total daily hours / / / / / / /

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