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					Year                    …………………………………………………….

Name/s                  ……………………………………………………


                                           KSS DEANERY
                                        APPLICATION FORM FOR

                                                         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


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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

       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

16.    Your regular availability at the training practice
                 Monday              Tuesday           Wednesday     Thursday        Friday         Saturday

17.    Where will you be at times you are unavailable for the FDP
                 Monday              Tuesday           Wednesday     Thursday        Friday         Saturday

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
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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
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) *


       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

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   _____________
       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
       ( We will publish name, address, telephone and, if applicable, e-mail

       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



       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 (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

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
       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?
                                                                                                
 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         
       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)

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

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
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?             
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
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
                                                                                                     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
         (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
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
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
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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Strictly Confidential – for KSS Deanery use only                                             Part 2; page 7

                              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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Strictly Confidential - for KSS Deanery use only                                               Part 2; page 8

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

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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: _______________________

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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.

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

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
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

How did you find out about this vacancy?
Please state publication:

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.

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