Year …………………………………………………….
Name/s ……………………………………………………
FOUNDATION TRAINING FOR GENERAL DENTAL
PRACTICE
KSS DEANERY
APPLICATION FORM FOR
TRAINER
For 2011/2012
This form to be used for new Trainer (first time) applications to this Deanery or for dentists who have previously been
trainers but have not completed this full application form for three years
It is important that you read the accompanying notes for applicants before
completing this form.
Please complete ALL sections and sign the declaration on part 2; page 7.
Failure to answer all the questions may result in your application not being
shortlisted. State not applicable (N/A) where appropriate.
When completing this form, please use black ink and BLOCK CAPITALS.
A copy of your last PCT Practice Inspection Report and copies of your latest NHS Mid
Year and End of Year Statements of Activity for your GDS/PDS Contract must be attached to
this application
(please see Part 2, Page 2 and Part 2, Page 8)
If this is a joint application please tick here and also use a joint application form
http://kssdeanery.org/dental
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PART 1
Personal Details
1. Title Last name First name
2. Practice address including postcode Home address including postcode
Tel. No. Tel. No.
Fax No. Mobile No.
E-mail: E-mail:
3. Qualifications (with dates)
Dental school
4. PCT on whose performer list you are included
Performer number
PCT in whose area the proposed practice is, if different
GDC registration number Annual practising certificate
Name of indemnity provider
5. Are you currently part of a dental body corporate? Yes No
Experience in general dental practice (please give dates and locations)
As a practice owner in present practice
As a practice owner elsewhere
As an associate/assistant
Previous experience in hospitals/CDS/other dental services (please give dates and
locations)
As a FDP (Foundation Dental Practitioner - trainee)
Name/year of scheme:
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6. Have you ever been, or applied to be, a Trainer in this or any other region? Yes No
If yes please state the year, the scheme and whether you were approved
Do you have a current application, or been appointed as a trainer in another region? Yes No
Please state region ____________
Please state whether the appointment was as a Sole or Joint Trainer _______________________
7. Previous and current salaried dental appointments Dates
8. Previous and current honorary appointments (ie BDA, GDPA etc) Dates
9. Appointments on professional bodies (ie LDC, BDA etc) Dates
10. Current membership of professional organisations
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11. Are you undertaking postgraduate dental/other qualifications? Yes No
Please detail:
12. In the last six years has a disciplinary committee ever found you in breach of your NHS terms of
service, or have you been subject to proceedings by the GDC? Please see notes on references on
Page 15
Yes No If yes, please give date _________
VDP Information
13. When is a vacancy for a FDP (trainee) likely to occur? ________________________
Will the FDP be
a) an additional dentist in the practice? Yes No
b) a replacement for a current dentist? Yes No
c) a follow-on FDP? Yes No
d) full-time in this practice? Yes No
Please specify actual times (use 24 hour clock) for questions 14 to 17.
14. FDP’s working hours outside term time (35 hours for full-time FDP)
Monday Tuesday Wednesday Thursday Friday Saturday
Am
Pm
Eve
16. Your regular availability at the training practice
Monday Tuesday Wednesday Thursday Friday Saturday
Am
Pm
Eve
17. Where will you be at times you are unavailable for the FDP
Monday Tuesday Wednesday Thursday Friday Saturday
Am
Pm
Eve
18. Dentist/s present in your absence, or, dentist whom the FDP may contact in your absence
Name Year of qualification Qualifications
Monday Tuesday Wednesday Thursday Friday Saturday
Am
Pm
Eve
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Practice Information
19a In how many other practices do you have a financial interest? _____________
List the other practices, the number of surgeries in each and enter days/times you attend these at 17
above.
19b If you provide dental services at any other locations, please list these and enter days/times you attend
these at 17 above
20. In the intended training practice, how many fully functional surgeries are there? ______________
a) Location
City Town Village
Main road Side road Shopping centre
Residential Industrial Commercial
Health centre Other (Specify): _____________________________
b) Design
Purpose-built Converted Single-storey Multi-storey
Wheelchair access Easy Difficult Impossible
Car-parking Private Street Difficult
21. Personnel Intended training practice Second practice Third practice
(if applicable) (if applicable)
Your status
Partners F/T
(with names) P/T
Associates F/T
(with names) P/T
Assistants F/T
(with names) P/T
Dental nurses F/T
(with names) *
P/T
Clerical F/T
(with names) P/T
Hygienists F/T
(with names) P/T
Technicians F/T
(with names) P/T
* Please state if Dental Nurses are registered or in training
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Practising Information
22. Detail, with reasons, any special training, interest or skills that you have which would be useful to your
FDP
23. The main practice contract:
a) covers mandatory services for all categories of patients Yes □ No □
b) is limited to certain patient groups:-
i) exempt and under 18’s only Yes □ No □
ii) under 18’s only Yes □ No □
iii)other – please detail Yes □ No □
c) covers some non-mandatory/additional (eg. Sedation, orthodontics Yes □ No □
or domicilaries) services – please detail
24. What arrangements are made for out of hours emergency patients?
25. To which specialists do you refer?
Practice Turnover
26. Workload
Please estimate the total number of patients in the proposed FT practice ___________
How many patients are currently treated within GDS/PDS arrangements in the
proposed FT practice? ___________
Please estimate the number of new NHS patient enquiries per month ___________
Estimate the proportion of your patients you personally treat within the NHS ___________%
Estimate the proportion of patients the practice treats within the NHS ___________%
Please estimate the likely number of patients immediately available to the FDP ___________
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27. Activity
What is your total practice UDA requirement for the year? _____________
What percentage of practice UDA requirement was achieved in the last financial _____________
year?
How many UDA’s did you personally complete in the last financial year? _____________
How many UDA’s do you expect to complete in the next financial year? _____________
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Practice Advertisement
Please use the same details as last year Yes □ No □
If no, please complete the following:
28. Should the practice be approved, details will be published on the KSS Dental Deanery’s Website
(http://kssdeanery.org/dental) We will publish name, address, telephone and, if applicable, e-mail
address.
Please provide the following additional information so that we can include accurate details on
the Website.
Name of Trainer(s)
Name of Practice (if applicable)
Address of Practice with Postcode
Telephone:
Email:
Your Website address:
How should applicants make contact in the first instance?
Who should applicants speak to if telephoning?
Who should applicants address mail to?
If you wish us to include further details, ie locality, type of work undertaken, surgery equipment, etc,
please include a short paragraph below. Alternatively, you could e-mail a short advertisement to
ihandy@kssdeanery.ac.uk (no graphics please)
The Deanery will be holding a Job Shop on Tuesday 1 February 2011 at Atrium 1 and 2, Guy’s
Hospital, London from 4.30pm. This event will be publicised to potential FDP’s, including final
year dental students.
Appointed Trainers will be invited to come along with suitable promotional material about their
practices, including photographs, practice brochures etc.
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Name of Applicant/s ________________________________
________________________________
PRACTICE QUESTIONNAIRE
PART 2
Training practices set the standards for new graduates, so it is important that, as far as possible, they comply
with current legislation. A practitioner who wishes to be a Trainer must have reasonable experience within,
and commitment to, the General Dental Services and demonstrate standards of good practice in keeping with
current opinion. Please read every section carefully and tick the boxes as appropriate: it is essential that ALL
questions are answered. If necessary, further information may be obtained from the offices of the KSS
Deanery Foundation Training Department, or from your Course Programme Director in General Dental
Practice. Supporting evidence may be required to be seen by the practice visitor(s). Original certificates and
other relevant documentation need to be available for inspection during the visit.
Yes or No, or
N/A not applicable
SECTION 2.1 The Practitioner Applicant
1st 2nd
(Joint applicant to complete second column.)
Are you practising in the General Dental Services providing a wide range of NHS
a)
treatment to patients?
b) Have you, or in the case of joint applicants, one of the pair of applicants been a
principal in the intended training practice for at least one year?
But
c) If you are an associate, you may, in exceptional circumstances, apply to be a sole
Trainer when all other requirements are satisfied and if you have been in this
practice for at least two years and will have complete control and responsibility for
managing your part of the practice in relation to the FDP.
d) Have you completed at least 75 hours of verifiable postgraduate education in the
past five years?
e) Have you completed any or all of the FGDP key/core skills? All Date
If some of the key/core skills – please give details of which, and dates …………… ………………….
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
f) Have you or your practice taken part in any other recognised clinical governance
scheme?
Name of Scheme …………………………………………………………………
Date of initial completion ………………………………………………………..
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Yes or No or
N/A not applicable
SECTION 2.2 The Practice
Date of last PCT Practice Inspection Report ………………………………. (please attach a copy)
(if you do not have a copy of this report, please explain the reason why this is not available)
2.2.1 EMPLOYMENT
a) Contracts: Are there written contracts of employment for all eligible members of staff?
1978 Employment (Protection) Consolidation Act ISBN 0 10 544478 2
b) Legislation: Do these contracts conform to the employment legislation’s minimum entitlements?
c) PAYE: Are employees provided with regular itemised payslips?
I attach a PCT Practice Inspection Report (where the inspection was carried out less than three years ago) and
any subsequent correspondence Yes No If yes, please proceed to Section 2.4.
If you have not had a PCT Practice Inspection within three years, please complete Sections 2.2.2 to 2.3.4.
2.2.2 HEALTH AND SAFETY (Health and Safety at Work etc. Act 1974, the Factories Act 1961 and the Offices,
Shops and Railway Premises Act 1963).
a) Poster: Is there a poster on display from the Health and Safety Executive? HSE Poster: ISBN 0 7176 2493
5
b) Policy: Is there a recently updated written safety policy for the practice on display or accessible to all staff?
See Writing a safety policy: advice for employers Ref HSC6
c) Risk Assessment: Has a risk assessment been carried out to identify the hazards within the
practice? Have the risks been assessed? Have assessments been made of all the substances used
within the practice to identify which might be hazardous to health? Have the risks been assessed?
Are records of these assessments available? Specific risk assessment is required for young
persons and new and expectant mothers (preferably in writing). Management of Health and Safety at
Work Regulations 1999; Five Steps to Risk Assessment IND (G) 163L; Control of Substances Hazardous to
Health Regulations 1999; General COSHH ACOP ISBN 0 7176 1670 3; A step by step guide to COSHH
assessment ISBN 0 11 886379
d) Welfare: Have you provided adequate facilities and arrangements for staff welfare as required by
the Workplace (Health, Safety and Welfare) Regulations 1992? Workplace health, safety and welfare
ACOP ISBN 0 11 886333 9
e) Fire: Is there adequate fire fighting equipment and means of fire detection throughout the practice
and are staff trained to deal with such situations? Is there a fire escape and is it adequately
signposted? Are passages free from obstruction? Are fire extinguishers regularly inspected and
serviced? Fire Precautions Act 1971 ISBN 0 10 544071; Fire Precautions (Workplace) Regulations 1997
f) Public Liability: Do you have adequate public liability insurance to cover your premises? Is a
certificate displayed? Occupier’s Liability Act 1957 ISBN 0 10 850198 1 and 1984 ISBN 0 10 540384 9
g) Employer’s Liability: Have you on display a current employer’s liability insurance certificate?
Employer’s Liability (Compulsory Insurance) Act 1969 ISBN 0 10 545769 8
h) First Aid: Is there adequate first aid provision? Has a suitable person been appointed to give first
aid and is this information displayed? Health and Safety (First Aid) Regulations 1981 SI No 917; Heath
and Safety (First Aid) Regulations 1981 ACOP ISBN 0 7176 1050 0
i) Accidents/RIDDOR: Is there an accident report book available and maintained? Are there systems
in place for reporting relevant incidents to the HSE? Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations 19995 SI No 3163; A guide to RIDDOR ’95 ISBN 0 7176 1012 8
j) Waste Disposal: Is waste segregated into non-clinical, clinical and special waste and stored safely
prior to disposal? Are there arrangements for the collection and disposal of these wastes? Are
copies of the transfer notes and consignment notes available? Environmental Protection Act 1991;
Special Waste Regulations 1996
k) Mercury: Is there a mercury spillage kit? Are staff aware of the procedure to deal with mercury
spillage? Is there proper storage (and disposal) of metallic mercury and waste mercury material?
Please confirm all three questions.
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Yes or No,
or N/A not applicable
l) Autoclave: Is there an inspection certificate? Is there a service/maintenance contract in place?
Pressure Systems & Transportable Gas Containers Regulations 1989; HSE IND (S) 27(L) 50M 2/90;
Provision and Use of Work Equipment Regulations 1992 SI No 2932
m) Compressors: Is there an inspection certificate? Is there a service/maintenance contract in place?
The Pressure Systems Safety Regulations 2000, SI 2000 No 128, ISBN 0 11 085836 0; Provision and Use
of Work Equipment Regulations 1992 SI No 2932
n) Gas Cylinders: Are they properly stored? Are the cylinders regularly serviced? Are records of
servicing available? HSE Pamphlet IND(S)27(L) 50M 2/90
o) Electrical Appliances: Are regular visual inspections of all portable equipment carried out? Are
records available? Is all portable electrical equipment and the fixed supply inspected and tested at
least every three to five years by a competent person? Are records available? Electricity At Work
Regulations 1989; Maintaining portable electrical equipment in offices and other low-risk environments
IND (G) 160L
p) Radiation: Have you informed the Health and Safety Executive of your x-ray machines? Have
you appointed a radiation protection adviser? Is there documentation of regular radiation safety
assessment of all radiographic equipment? Are there local rules on display? Are all staff using x-
ray equipment adequately trained and records of training kept? Is the quality of radiographic
processing and radiographic images continually assessed? DH publication “Radiation Protection in
Dental Practice” and “Radiological Protection July 1988”; TPMDE video “ALARA”; Guidelines on
Radiology Standards for Primary Dental Care, Report by Royal College of Radiologists and the NRPB 1994
q) Laser: If you use a laser, are you registered with your district health authority? Are local rules
available? Nursing Homes (Laser) Regulations 1984; HN(84) 16 Publication ISBN011 320857 X .
r) Computers & Display Screen Equipment: If you use a computer, are you registered with the
Office of Data Protection? Do you comply with the Health and Safety (Display Screen
Equipment) Regulations 1992? Has an assessment of the workstation been carried out? Have
employees using DSE regularly been offered eye and eyesight tests? Data Protection Act 1998;
90/270/EEC; Health and Safety (Display Screen Equipment) Regulations 1992; Display screen equipment
work – guidance on regulations ISBN 0 11 886331 2
s) Drugs: Do you have the emergency drugs recommended for dentists in the latest BNF?
Are emergency drugs kept securely, but accessible at all times? Are strict records kept of the
purchase and dispensing of drugs? Are drugs stored according to manufacturers’ recommendations
and kept in a locked cupboard? Misuse of Drugs Act 1971 ISBN 1 85197 4121; Misuse of Drugs (Safe
Custody) Regulations 1973; Medicines Act 1968 ISBN 0 10 546768 5
t) Laboratory: If there is a laboratory on the premises has an assessment been made under the
Factories Act and other special legal requirements?
SECTION 2.3 Good Practice
2.3.1 EMERGENCIES
a) Does the practice record and regularly update patient medical history?
b) Is there a pocket mask?
c) Is there an up-to-date emergency drugs kit?
d) Is there an oxygen kit?
e) Are staff trained regularly in resuscitation? (Date____________)
f) If your practice undertakes inhalation or intravenous sedation, does your practice conform to the
current recommendations?
g) Is there a first aid kit and is there a qualified first-aider or appointed person to give first aid?
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Yes or No or
N/A not applicable
2.3.2 INFECTION CONTROL
a) Are staff trained in infection control? (Date _____________)
b) Are staff vaccinated against Hepatitis B and the other common illnesses; diphtheria, pertussis,
poliomyelitis, rubella, tetanus, TB?
Are reports available indicating responses to the Hepatitis B vaccine and when boosters are due?
c) Is there an autoclave? (Make/Model __________________________)
d) Is the autoclave regularly serviced and tested? (Date _____________)
e) Is there an ultrasonic bath/washer disinfector?
f) Are all non-disposable clinical instruments, including burs and handpieces, sterilised after use?
g) Are there at least three of each of the following for the sole use of the VDP:
Slow hand pieces? three-in-one tips?
Ultrasonic tips? turbines?
h) Are clinical items sent to others (eg impressions to the laboratory) properly
treated for cross-infection control?
i) Do members of the practice either dispose of or sterilise between patients the following items:
aspirator tips? impression trays?
j) Do members of the practice use disposable:
paper towels? surgical blades?
local anaesthetic? gloves?
needles? facemasks?
mouthwash cups?
k) Is eye protection provided & used by staff and patients?
l) Is there appropriate and adequate ventilation of the premises, especially
treatment rooms, sterilising rooms, storage areas and developing areas?
m) Does the practice comply with the “essential” requirements of HTM 01-05?
2.3.3 FACILITIES FOR THE FDP
a) Is the FDP’s surgery greater than 9 square metres?
b) Is the surgery suitable for low-seated dentistry?
c) Is there regular provision for a trained dental nurse for the FDP?
d) Is there a light cure unit?
e) Is there a well-stocked rubber dam kit?
f) Are there adequate instruments available for examinations, conservation, endodontics,
periodontics, oral surgery and prosthetics?
g) Is there a reasonable practice library?
h) Can the practice provide the FDP with more than 10 patients per day?
i) Is there a viewer for radiographs?
j) Are beam-aiming devices available for bitewing, periapical and endodontic radiography?
k) Does the practice have facilities for clinical photography?
l) Is there a computer with broadband access that the FDP can easily access?
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Yes or No or
N/A not applicable
2.3.4 DOCUMENTATION
Are copies of the following documentation available for inspection or on display:
a) Health and Safety poster?
b) Practice policy on health and safety?
c) Autoclave maintenance and inspection?
d) Compressor maintenance and inspection?
e) Fire equipment maintenance?
f) Performing Rights Licence and/or TV licence (if applicable)?
g) Records relating to safety checks on:
(i) portable electrical equipment?
(ii) the fixed electrical supply? (NICEIC Test Certificate)
h) Data protection registration (if applicable)?
i) Computer software licence (if applicable)?
j) Employer’s liability insurance certificate?
k) Current Certificate of professional indemnity? Expiry Date …………………………………….
l) GDC annual practising certificate?
m) Risk assessment and COSHH assessments?
n) Clinical waste transfer contract (for sharps and other clinical waste) Provider …………………….
Transfer Note for period ……………………………..
Hazardous waste disposal contract Provider ……………………………………………...
Transfer Note for period
o) Records relating to radiation safety assessment of all radiographic equipment?
Details/Location of Date of Safety Details/Location of Date of Safety
X-Ray Machine Assessment X-Ray Machine Assessment
……………………… ……………………… ……………………… ………………………
……………………… ……………………… ……………………… ………………………
……………………… ……………………… ……………………… ………………………
p) Local rules for radiographic equipment?
q) Records of quality assessment systems for radiographs
r) Registration with the Care Quality Commission
SECTION 2.4 Trainer Responsibilities Applicant
st
1 2nd
If appointed, will you (joint applicant to complete second column):
a) appoint a suitable candidate in accordance with the Deanery appointment process and
employ the FDP as a salaried performer under the standard Trainer/FDP contract?
(Details are attached.)
b) (i) for new trainers, attend the Trainer induction course (two days for new
trainers), any trainer study days and participate in the trainer appraisal
process
(ii) for experienced trainers attend any trainer study days, participate in the
trainer appraisal process and undertake those activities and learning as
agreed in your Personal Development Plan (These courses seek to indicate
methods of preparing the practice for a FDP and help to develop the skills
required to become a good Trainer and teacher.)
c) Attend the KSS Deanery FDT Job Shop
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Yes or
No or
N/A not
applicable
d) be available for the FDP for day-to-day guidance in the practice on a minimum of six
sessions a week? (One session being half-a-day.)
e) provide help on request to the FDP?
f) Complete the FDT personal development portfolio (PDP) and carry out all assessments
that this contains. Assist the FDP to complete the PDP. Report all problems
completing the PDP to the Course Programme Director
g) provide a protected teaching time (tutorial) of at least one hour per week during normal
practice working hours?
h) for full-time trainer applications to employ the FDP for 28 hours per week during those
weeks with a study day and 35 hours at all other times (and pro rata for part-time
applications)
i) provide for the FDP satisfactory facilities, materials and experienced chairside and
clerical assistance?
j) ensure that the FDP is reasonably occupied, has clinical freedom and can experience a
wide range of NHS dentistry?
k) ensure that the FDP attends the study days course? (Absence for reasons other than
sickness shall only be allowed in exceptional circumstances. Repeated and unexplained
absences may be interpreted as a withdrawal from the scheme by both the Trainer and
the FDP.)
l) attend meetings when reasonably requested to do so by the Course Programme Director
(These are usually held each term in the afternoon/evening at the postgraduate centre
concerned.)
m) attend fourteen sessions of FT-related postgraduate education during the training year?
(this should include at least one session per term on the study days course.)
n) Keep the Course Programme Director and your PCT etc., informed of any alteration in
the circumstances of your practice, your training involvement, your commitments or
your FDP’s, that would affect the Trainer/FDP contract?
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PLEASE READ THE FOLLOWING STATEMENTS BEFORE
SIGNING THIS FORM
(In the case of joint applicants, both must sign this form)
1. I/we have read both parts of the form and have completed the sections to the best of
my/our knowledge.
2. I/we agree to a practice inspection, if appropriate, and will make approximately one
hour available to the visitors.
3. I/we accept that references will be taken up. I/we give consent for the Deanery to
approach the GDC to ask whether a certificate of good standing would be issued, if
requested. I/we also consent for the Deanery to contact the Primary Care Trust on
whose performer list I am included and also the PCT in whose area I work (if this is
different). The Deanery will ask the PCT for information on:-
a) Breaches of the practice contract and any action taken which may affect the suitability of the
practice for Foundation Training.
b) Type of contract – full or limited – details, if training limited
c) If contract activity at the practice is stable or increasing/reducing
d) Date of last practice inspection and next practice inspection due. Any outstanding items after the
last practice inspection.
e) Any performance issues or serious substantiated complaints affecting the applicant
f) Any performers list issues relating to the applicant including conditional inclusion, suspension,
contingent removal or removal
4. I/we shall accept the decision of the selection committee.
5. I/we understand that if I am/we are selected as Trainer/s, I/we will be required to
comply with the Deanery policy and procedures for appointing FDPs and to employ the
FDP under the standard Trainer/FDP contract.
SIGNED:_________________________________________________ DATE:________________
NAME _________________________________________________ (please print)
SIGNED:_________________________________________________ DATE:_______________
(Joint Applicant)
NAME _________________________________________________ (please print)
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For applications where the applicant is not the provider/group
contract holder
Details of Provider – names of partners/Corporate Body etc.
I/we agree to the KSS Deanery obtaining the above information from the PCT responsible for the
contract(s) at the practice(s), which this application relates to.
I/we will support the applicant in ensuring that they, and their FDP, comply with the terms and
conditions for dental vocational training with KSS Deanery (General Information for Approval as a
Trainer Booklet).
SIGNED:_________________________________________________ DATE:________________
NAME _________________________________________________ (please print)
Authorised Signatory on behalf of ________________________________________________
When this form has been completed and signed, please attach:-
1) a copy of your practice information leaflet
2) recent practice inspection document (less than three years old)
3) a copy of your latest NHS End of Year Statement of Activity for your GDS/PDS contract
4) a copy of the 2009/2010 Mid Year Statement of Activity for your GDS/PDS contract
5) a copy of your CPD record for the last two complete years for verifiable CPD
6) details of your sources of non verifiable CPD
7) if you are an existing or recent trainer, details of the VT/FDT run sessions you have attended
in the past two years
and send to the Dental Foundation Training Office, The Postgraduate Deanery for Kent, Surrey and
Sussex, 7 Bermondsey Street, London SE1 2DD by the notified closing date. Receipt will be
acknowledged.
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Postgraduate Medical and Dental Education
for Kent, Surrey & Sussex
Data Protection Act 1998 – Dental Foundation Trainers
You are providing us with personal information. This document lets you know about how we will
use the information and seeks your agreement to the processing of your data in the ways
described below. You will be contacted separately for your agreement if we need to use your
information in a different way. The Data Controller is the NHS South East Coast Strategic Health
Authority. Any questions should be directed to the Dental Foundation Training Officer, The KSS
Deanery, 7 Bermondsey Street, London SE1 2DD.
Information contained in or derived from this application will be held in manual files and entered
into a database. The information will be shared with the selection panel, which will be comprised
of personnel from a number of organisations representing Postgraduate Dental Education as well
as employees of the University of London. The information will be utilised for selection and for the
production of monitoring statistics. Additionally the information will be used to carry out checks on
your appropriateness for the position. These checks will involve contacting the Department of
Health to identify whether you have breached any terms of NHS Service and the General Dental
Council to identify whether there are any disciplinary proceedings against you. The time period
that the checks cover will be the proceeding 6 years. Information supplied by unsuccessful
applicants (including information derived from verification checks and interview notes) will be held
for 6 months and then disposed of confidentially.
Information from successful applicants will be kept for the purposes of administrating your role as
an agent of the KSS Dental Deanery; for the administration of accounts and records in respect of
your expenses; in respect of your educational role with trainees; and for research purposes. The
application form will be kept for the duration of your time as a Trainer. The type of information held
will include personal details, education and training details, financial details and data classified
under the Data Protection Act as sensitive i.e. racial or ethnic origin. The sensitive data will be
held for the purpose of monitoring equality of opportunity only. The types of people/organisations
that will have access to all or some of this information will be: the General Dental Council and your
Primary Care Trust.
Data subjects have the right to be told about and to be provided with intelligible copies of any
personal data held on computer or in a paper-based filing system upon request.
In addition, as indicated at the end of Part 1 of the application form, certain data, namely
your name and practice address, will be placed on the KSS Deanery website. If you object to
this please contact the Dental Foundation Training Officer, The KSS Deanery, 7 Bermondsey
Street, London SE1 2DD.
_____________________________________________________________________________
I hereby consent to the processing of all data, including sensitive data, outlined above.
Signed: ________________________________ Date: _______________________
R:\DENTAL\IRIS\KSS\Applications 2011-2012\Trainer October 2010.doc
EQUAL
OPPORTUNITIES
MONITORING
FORM
We are committed to Equal Opportunities in Employment and as part of this policy all applicants for approval as a
Foundation Trainer are asked to complete the details requested below. This information will be used for monitoring
purposes only and will not be part of the information used in deciding to invite you for interview.
Name:
Post applied for:
Please indicate your sex by ticking the appropriate box: Male Female
Please state your date of birth:
DISABILITY MONITORING
Do you have a disability? Yes No
If yes, please give brief details
of your disability.
If you choose not to detail
your disability on the
application form, please detail
any duty or working
arrangement, which your
impairment prevents you from
meeting.
ETHNIC MINORITY Please tick one box only. If ticking ‘OTHER’, please add description
Asian/Asian Asian/Asia Other Black White - English
British - n British - Origin
Bangladeshi Pakistani
Asian - Asian/Asia Mixed – White & White – Welsh
Chinese n British – Asian
Indian
Other Other Mixed – White & White – Irish
Chinese Asian Black African
Ethnicity Origin
Black/Black Black/Blac Mixed – White & Other - White
British - k British - Black Caribbean
African Caribbean
Other White - British
Mixed
Origin
How did you find out about this vacancy?
Please state publication:
DECLARATION
I declare that the information above is, to the best of my knowledge, correct. I agree to this sensitive and personal data
R:\DENTAL\IRIS\KSS\Applications 2011-2012\Trainer October 2010.doc
being processed for the purposes of monitoring the effectiveness of the South East Coast Strategic Health Authority Equal
Opportunities Policy.