Application form for Trainers
Please note - applications will only be accepted on this original form
Feb 2012
Contents
- Trainer Application form
- Postgraduate Activity
- Practice self assessment
- Equal Opportunity monitoring
- Practice visit check list
- Interview score sheet
- Trainer person specification
- Therapist employment contract template
West Midlands Dental Therapist Foundation Training Scheme
1.Name ……………………………………………………………………………….....
2.Practice Address ………………………………………………………………………...
……………………………………………………………………………………………
Email Address: ......
Tel (with STD Code) Day: - ………………………………..
Evening: - …………………………
3.Please indicate PCT: - …………………………………….
Personal No: - ……………………….
National Insurance No: - …………………………………
GDC No: - …………..……………...
4.Qualifications (with dates and School) …………………………………………………………………………………………………
…………………………………………………………………………………………………
5.Protection Society …………………………………...
6.Number of years in 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………………………………………………………………………………
9 (i).Have you been involved in a Vocational Training Scheme as a Trainer or a Therapist? If so give details
……………………………………………………….………..………….
9 (ii).Have you had a previous Deanery practice visit? If so, when?
…………………………………………………………………………………..
10.Please indicate all other dental appointments held since qualification
Present
………………………………………………………………………………
Previous………………………………………………………………………
11(i) Please list the postgraduate courses you have attended in chronological order over the past three years and the subject matter of any audits or peer reviews you have undertaken including dates. Highlight when you attended the core CPD requirements. It is recommended you use a separate sheet when including this information see page 8.
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
11 (ii).What experiences have you of Equal Opportunities, Fair Recruitment and selection procedures? Please give details.
…………………………………………………………………………………………..
12.If you have had any dispute with the General Dental Council or a Health Authority/PCT, please give details.
………………………………………………………………………………………………
13.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)......
14.How many surgeries are there in the practice?
a) Fully equipped ………………………………………………………………………..
b) Partly equipped ……………………………………………………………………….
15.Are there any aspects of dental care not provided in the practice? (Please specify)
16.Please indicate where the technical work required for your practice is undertaken.
Acrylic......
Crown & bridge......
Orthodontic......
Other......
17.Are there any restrictions on the type of patients accepted for treatment in your practice?(Please specify)
…………………………………………………………………………………
18.Do patients in the practice have freedom to choose their own dentist?
………………………………………………………………………………………
19.Will the Therapist take over an existing group of patients?
……………………………………………………………………………………
If not, how many new patients per week will be available to the Therapist?
………………………………………………………..
How many days’ work per week will be available to the Therapist?
…………………………………………………………
20.Will you be prepared to engage in a formal weekly discussion period during normal practice working hours?
…………………………………………………………………………………
21.Would you be willing to complete a termly report on the Therapist’s progress?
……………………………………………………………………………………….
22.When would you like a Therapist to commence?
………………………………………………………………………………………………..
23.Please show the sessions when you would be present in the practice and carrying out clinical work at the same time as the Therapist
Monday / Tuesday / Wednesday / Thursday / Friday / Saturdayam
pm
I understand that if I am approved as a Trainer:-
(i)I will be required to employ my Foundation Therapist under a Practice 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 Therapist 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 the Deanery is obliged to report any circumstances where patient safety is an issue
(v)I agree to inform the Deanery of any Criminal Investigation or Conviction or Disciplinary, GDC or PCT Investigation or findings, as soon as you become aware of them.
Signature: ……………………………………………… Date: ……………………….
Please complete the above form, self assessment
Document and practice description attached and return to
the address below.
West Midlands Strategic Health Authority
Workforce Deanery
St Chad’s Court
213 Hagley Road
Edgbaston
Birmingham, B16 9RG
Postgraduate course attendance in the past 3 years
Course Title / Date / Venue / CPD HoursAudits/Peer Review
Subject matter / Date / CPD Hours(Please highlight core CPD requirements and use separate sheet for further courses attended)
Your Practice
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 Office, together with your application form as soon as possible. A practice visit and interview date 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 Therapist 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 Therapist surgery?
Where would you hold tutorials?
The Foundation Dental Therapist 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 Therapist have hand, sonic or ultrasonic scalers?
Where, and with what equipment, will the Therapist take and view intra-oral radiographs?
How many handpieces of the various types will be available to the Therapist?
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?
6.Cross Infection
How is cross infection control managed in your practice?
Are you confident that, even if an item of equipment fails, you can still provide a regime to current acceptable standards?
What 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 Therapist?
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
Details of contract with PCT
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 PCT within the nGDS.
Describe your contribution to fulfilling the requirements of this contract.
What has been your previous experience with Associates, Performers and Therapist’s?
15.Relationships
What are your views concerning working with a Therapist?
Would there be any constraints on the type of treatment your Therapist 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 form, the application form, and practice description and return as soon as possible to:
West Midlands Strategic Health Authority
Workforce Deanery
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
Date of birth: ___/___/___
(Delete as appropriate) (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:
West Midlands Strategic Health Authority
Workforce Deanery
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 Therapists; please ensure that this is a full and accurate description as the Therapist 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 indicate arrangements you prefer for interview.
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 Therapist' if they wish to visit the practice prior to completion of the recruitment process.
Please return together with application form as indicated – you are advised to keep a photocopy of all your application forms.
Practice Visit Checklist
This section is included for the Trainer applicant. The visitors use the proforma below when reviewing the practice. Please note the sections marked with an asterisk (*). These indicate essential items which must be present in the practice. Their absence automatically precludes acceptance as a training practice.
1. Practice Premises
Location
City
/
/Town
/
/ Village / Main Road
/
/Side Road
/
/Shopping Centre
/
Residential
/
/Industrial
/
/Commercial
/
Health Centre
/
/Other …………………………………………
Design
Purpose built / / Converted / / Age ………… yearsSingle storey / / Multistorey / / Upper storey /
Disability Audit
Measures taken to comply where practical
Car Parking
Private / / Public / / Street / Difficult /
Reception Facilities *
Reception Desk / / Waiting room / / Adequate seating / WCs
Patients’ / / Staff / / Joint use Staff Rest Area
Yes / / No / / Joint use Décor & Maintenance
Good décor / / Good maintenance / / Cleaner employed / Good cleanliness /
Surgeries (Number)
Dentist …………….(Fully equipped) / Hygienist …………..
(Partially equipped) / Other ……………
Plans for Renewal and Refurbishment……………………………………………………………
2. Appointments & Records
Appointment Books *
Manual / / Computerised / Clarity / / Realistic timings * /
Provision for emergencies / / Recalls /
Appropriate recall intervals /
Time booked ahead ……………..
Practice hours ……………………………………………………………………
Record Storage *
Manual / / Computerised / / Cabinets / Cabinets / / Drawers / / Open shelf /
Rotary / / Other / / ……………………………..
Record Quality
Manual / / Computerised / Medical history *
Operator identified * /
/ Regularly updated /
Clarity / / Base charting * /
Periodontal assessment * / / Treatment plans /
Radiographic quality / Usage
Intraoral / ………………….. / Intraoral / …………………….
Panoral
Prescriptions / …………………..
/ Panoral
Reports / …………………….
Storage / ….………………. / Comments / …………………….
Computer Use
Patient lists / / Recalls / / Appointments / Full records / / EDT / / Other …………………
Software used …………………………………………
Use of FPI7
3. FDT’s Surgery
9 sq metres * / / Floor covering * / Low seated design * / / Four-handed design /
Modern cabinetry * / / Tidy /
Décor & maintenance / / Stools * /
Unit type * …………………… Chair * ………………. Age (years) ……
Amalgamator * / / Operating light * /
Curing light * / / Calibration Recorded * /
Mechanical scaler * / / Intra-oral X-ray set /
Chairside X-ray viewer * / / Suitable for left handed dentist /
Is this surgery available for five days per week as required? * /
Instrumentation
No of turbines (min 3) * …………. / RA handpieces (min 3) * ………Straight handpieces * ……………. / 3 in 1 tip * ………………………..
Examination * / / Periodontal * /
Conservation * / / Surgical * /
Endodontics / / Prosthetics * /
Forceps/elevators * / / Rubber dam kit * /
Aspirating syringes / / Articulators /
Other Facilities
Gloves * / / Masks / / Eye protection * / Materials * / / Bibs /
Relationship to Trainer’s surgery ……………………………………………..
……………………………………………………………………………………..
4. Trainer’s Surgery
Low seated design / / Floor covering / Modern cabinetry / / Four-handed design /
Décor & maintenance / / Tidy /
Chairside X-ray viewer / / Stools /
Unit type ……………………….. Chair …………………. Age (years) ……
Amalgamator / / Operating light /
Curing light / / Calibration Recorded /
Mechanical scaler / / Intra-oral X-ray set /
Instrumentation
No of turbines (min 3) ……………. / RA handpieces (min 3) ………….Straight handpieces ……………. / 3 in 1 tip …………………………..
Examination / / Periodontal /
Conservation / / Surgical /
Endodontics / / Prosthetics /
Forceps/elevators / / Rubber dam kit /
Aspirating syringes / / Articulators /
Other Facilities
Gloves / / Masks / / Eye protection / Materials / / Bibs /
5.Cross Infection Control
Tray system * / / Instrument cleanliness * / Handpiece sterilisation * / / Ultrasonic bath /
Suitable storage / / Chemical Disinfectants /
Impression disinfection / / Towels paper/roller /
Beakers / / Zoning /
Handscrubs / / Liquid soaps /
Surface disinfection / / Sharps disposal /
Clinical waste disposal * / / Water line disinfection/cleaning /
Autoclaves * / / / Number ………………………
Washer/disinfector /
6. Radiographic Facilities
Intra-oral machines * No. ………….. Type …………….. Age ………….Central / / In all surgeries / / In FD surgery /
OPT / / Hand processing / / Darkroom /
Automatic processing / / Monitors
Digital /
/ Film holders /
Core of knowledge * / / Local rules * / / Collimation /
Protocol for Accidental Over-exposure /
Quality Assurance System /
Patient visible during exposures /
7. Compressors & Suction
Compressor No …………………… / Maintenance arrangement / Filters / / Gas cylinders stored safely /
Central suction system / / In-surgery suction system /
Safe venting for suction systems * / / Amalgam Filtration /
- Emergency Equipment & Training
Airways * / / Oxygen* /
Forced ventilation possible * / / Portable aspirator * /
Emergency drugs * / / Expiry dates monitored * /
CPR training * / / Date of last session ………………
First Aid Kit
Sedation /
/ Mercury Spill Kit
Relative Analgesia /
Sedation/RA compliant with current best practice /
9. Library
Textbooks / / Journals / / DPF/BNF * / nGDS Contract details / / Clinical Photography / / IT Facilities /
CAL / / Internet Access* /
Venue for Tutorials…………………………………………………………………..
10.Workload
Outgoing dentist / / No. patient records in practice .……..New book / / No. new patients per month ………..
Patient numbers increasing / / No. FTE dentists …………………..
Practice contract values UDAs/UOAs………… / Trainer’s contract values UDAs/UOAs………
£ …………….. / £…………….
Private/NHS % ……;./………….