Dental Boa rd Form Application for Limited Registration for Postgraduate Training or Supervised Practise PSDWS ALPS 20

8/12/2019 Dental Boa rd Form Application for Limited Registration for Postgraduate Training or Supervised Practise PSDWS AL

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OFFICE USE ONLY

Application for limited registrationfor post graduate training orsupervised practiceas a Dentist (Public Sector Dental Workforce Scheme)

Section 77 of the Health Practitioner Regulation National Law Act(the National Law)

ALPS-20

*ALPS-20*

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This form is to be used by appropriately qualified overseas trainedDentists who do not qualify for general or specialist registration

and wish to apply for limited registration to undertake postgraduate

training or supervised practice in public sector employment in

Australia for the first time, or if previously registered and there has

been a substantial change in the employment circumstances.

Applicants eligible for limited registration - Public Sector Dental

Workforce (PSDW) Scheme for postgraduate training or supervised

practice are graduates from the Australian Dental Council (ADC)

approved undergraduate dental programs in Canada, Hong Kong,

Ireland, Malaysia, Singapore, South Africa, United Kingdom and

the United States (www.adc.org.au). These eligible applicants aregranted an exemption from the ADC Preliminary Examination.

PSDW Scheme candidates granted exemption from the ADCs

Preliminary Examination are required to undertake, and successfully

complete, the ADC Final Examination within three years of first

participating in the PSDW Scheme.

It is a requirement if granted limited registration - PSDW Scheme,

that the registrants must notify the ADC as soon as possible after

PSDW Scheme limited registrationis granted:

This application will not be considered unless it is complete and

all supporting documentation has been provided. All supportingdocumentation must be:

certified in accordance with the Australian Health Practitioner

Regulation Agencys (AHPRA) guidelines; and

in English. If original documents are not in English, you must

provide a certified copy of the original document and translation

in accordance with AHPRAs guidelines.

DO NOT send original documents.

It is important that you refer to the Boards Registration Standards,

Codes, and Guidelines when completing the form. These documentscan be found at www.dentalboard.gov.au

PRIVACY AND CONFIDENTIALITY

The information collected in this form is authorised or required under the

National Law for the purposes of determining an applicants eligibility for

registration and to provide for the protection of the public by ensuring

that only health practitioners who are suitable persons and qualified to

practise in a competent and ethical manner are registered.

Information supplied on this form may be provided to other persons

and agencies for workforce planning, information management and

communication, criminal history and identity checking and other purposes

as specified by the National Law.

SECTION A: Personal details and identification

Note: The information items in this section of the application that aremarked with an asterisk (*) will appear on the public register.

Family (legal) name

First given name

Previous names and other names known by

Preferred name

MSex F

*

*

*

Middle given name(s)*

*

1. What is your name?

Mr Mrs Miss Ms Dr Other

COMPLETING YOUR APPLICATION

Read all instructions

Print clearly in BLOCK LETTERS using a black or blue pen

Place X in ALL applicable boxes:

The Dental Board of Australia and the Australian Health Practitioner

Regulation Agency are committed to ensuring the privacy and confidentiality

of personal information held and will adhere to the National Privacy

Principles under the Privacy Act 1988 (Cth) when collecting, using,

disclosing, securing and providing access to private information.

! PART A: TO BE COMPLETED BY APPLICANT

ALPS-20 Effective from: 1 August 2013


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ALPS-20 Effective from: 1 August 2013 Page 3 of 13

SECTION B: Qualification for the profession

In accordance with section 66 of the Act, to be eligible for

limited registration - PSDW Scheme for postgraduate training or

supervised practice you must be able to demonstrate to the Board

that you qualify to practise as a dentist under limited registration

in the health profession.

To qualify, you must be able to provide evidence of a qualification

from the Australia Dental Council (ADC) approved undergraduate

dental programs in Canada, Hong Kong, Ireland, Malaysia,

Singapore, South Africa, United Kingdom and the United States list

of the approved undergraduate dental programs accepted can be

found at www.adc.org.au9. Your contact details

During business hours

( )

After hours

( )

Mobile

Email

Title of qualification

Name of institution (University/College/Examining Body)

Country

Completion date Length of program

2 Additional qualification and examinations/assessments

MM YYYY

Attach a separate sheet if all your qualification details do not

fit within the spaces provided.

11. What are the details of your qualification in dentistry?

Title of qualification

Name of institution (University/College/Examining Body)

Country

1 Primary qualification and examinations/assessments

Completion date Length of program

MM YYYY

You must attach an original certified copy of your primary

dental degree certificate that indicates completion of a course

of study leading to a qualification as a dentist.

Residential address

Principal place of practice

Other (Provide your postal correspondence address below)

8. Where do you want postal correspondence delivered to?

Suburb

State/

Territory Postcode

Country

No. Street

10. Would you like to receive your renewal communications

electronically?

Some communication will always be sent by post

Yes Send my renewal notices to the email addressnominated above

No Go to Section B: Qualification for the profession


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SECTION C: Registration history

12. Please read this before answering the following questionabout registration history:

What is your health practitioner registration history?

State/Territory/Country

1 Most recent registration

DD MM YYYY

Period of registration

DD MM YYYYto


2 Additional registration

DD MM YYYY


DD MM YYYYto

Attach a separate sheet if all your registration history does not

fit within the spaces provided.


3 Additional registration

DD MM YYYY


DD MM YYYYto

The Board requires a Certificate of Registration Status or

Certificate of Good Standing from everyjurisdiction outsideof Australia in which you are currently, or have previously been

registered as a health practitioner during the last 5 years.

You MUSTarrange for original Certificates to be forwarded directlyfrom the licensing or registration authority to the

Dental Board of Australia.

SECTION D: Work history

13. What is your full practice history?

You must attach to your application a Curriculum Vitae that

describes your full practice history and any clinical training

undertaken. The information contained in your Curriculum

Vitae will further inform the Board in relation to your recency

of practice and registration history.

Your Curriculum Vitae must:

Detail any gaps in your practice history of more

than three months from the date you obtained your

qualification

Indicate whether positions were undertaken full-time or

part-time, and specify the nature of any practice (e.g.

provision of clinical care, management, administration,

education, research, advisory, regulatory or policy

development role)

Detail any additional study undertaken and qualifications

obtained

Be in chronological order

Be signed and dated with a statement This Curriculum

Vitae is true and correct as at (insert date)

Be the original signed Curriculum Vitae (no faxes or

scanned copies will be accepted).

It must also contain all the elements defined in AHPRAs

Standard Format for Curriculum Vitae which can be found at

www.ahpra.gov.au


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Please note that registration is dependent on suitability as defined

in the National Law, and the requirements set out in the Boards

Registration Standards.

Refer to www.dentalboard.gov.aufor further information.

Please read this before answering the following questionabout criminal history:

14.

SECTION E: Suitability statements

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Criminal history includes the following, whether inAustralia or overseas, at any time:

Every conviction of a person for an offence

Every plea of guilty or finding of guilt by a court of theperson for an offence, whether or not a conviction is

recorded for the offence

Every charge made against the person for an offence.

Under the National Law, spent convictions legislation does not

apply to criminal history disclosure requirements. Therefore,

a complete criminal history will be supplied to the Board

irrespective of the time that has lapsed since the charge was

laid or the finding of guilt was made.

The Board will decide whether a health practitioners criminal

history is relevant to the practice of the profession. For further

information on the factors the Board will consider in making this

decision, see the Criminal History Registration Standard,whichcan be found atwww.dentalboard.gov.au

You MUST attach a separate sheet with any additional details that

do not fit within the space provided.

No

No

Yes

Yes

Do you have any criminal history in Australia?

15. Do you have any criminal history in another country?

Go to the next question


Provide a full explanation of the circumstances and details

of your criminal history

Provide a full explanation of the circumstances and details

of your criminal history

Provide a full explanation of the circumstances and

details of your criminal history in Australia.

Provide a full explanation of the circumstances and

details of your criminal history overseas.

To be eligible for limited registration for post graduate

training or supervised practice - PSDW Scheme you must be

able to provide evidence of English language skills that meet the

Boards English Language Skills Registration Standard,which can

be found at www.dentalboard.gov.au

Please read this before answering the following questionsabout English language skills:

16.

Yes

No

Did you undertake your secondary education and your tertiary

qualifications in the profession, in English, in one of the

following countries:

Australia

Canada

New Zealand

Republic of Ireland

South Africa

United Kingdom

United States of America.

Go to question 20


18. On what date did you complete this examination?

DD MM YYYY

Date

Which of the English language examinations listed below have

you successfully completed?

International English Language Test Scheme (IELTS) -academic model

Occupational English test (OET)

You MUST arrange for a testing authority to provide

evidence of your successful completion of the Board

approved English language test directly to the relevant State

office of the Dental Board of Australia (for example, by secure

internet login).

Please read this before answering the following questionabout English language examinations:

17.

Note: Pass result must be obtained in one sitting.


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Yes

No

19. Have your results from the above mentioned Englishlanguage examinations been obtained within two yearsprior to applying for registration?


You MUST attach evidence that you have

actively maintained employment as a registered

health practitioner using English as the primarylanguage of practice in one of the following

countries:

Australia

Canada

New Zealand

Republic of Ireland

South Africa

United States of America

United Kingdom.

Yes

No

20. Do you commit to having appropriate professionalindemnity insurance arrangements in place for all practiceundertaken during the registration period?

For further information on requirements see the Boards

Professional Indemnity Insurance Registration Standard, which

can be found at www.dentalboard.gov.au


Please read this before answering the following questionsabout recency of practice:

21.

Practicemeans any role, whether remunerated or not,in which the individual uses their skills and knowledge

as a dental practitioner in their profession. In accordance with

the Recency of Practice Registration Standard, practice is not

restricted to the provision of direct clinical care. It also includes

working in a direct non-clinical relationship with clients; working

in management, administration, education, research, advisory,

regulatory or policy development roles; and any other roles that

impact on safe, effective delivery of services in the profession

and/or use their professional skills.

See requirement above (under Work history) to provide

Curriculum Vitae. For further information on requirements see

the Boards Recency of Practice Registration Standard, which

can be found at www.dentalboard.gov.au

Did you graduate more than 1 year ago?

No

Yes

Yes

No

Go to question 23


22. Have you practised the profession in the last five years?

If you have not practiced within the last five years,

provide details which address the requirements for

the recency of practice.


No

Yes

Do you have an impairment that detrimentally affects or is likely

to detrimentally affect your capacity to practise the profession?


Please read this before answering the following questionsabout health, conduct and performance:

23.

Impairmentmeans a physical or mental impairment,disability, condition, or disorder (including substance

abuse or dependence) that detrimentally affects or is likely to

detrimentally affect your capacity to practise the profession.

You MUST attach details of any impairments to

this application.

No

Yes

28. Have you been or are you the subject of conduct,performance or health proceedings whilst registered underthe National Law, a corresponding prior Act or the law ofanother jurisdiction in Australia or overseas, where thoseproceedings were not finalised?


You MUST attach details of any conduct

performance or health proceedings to this

application.

No

Yes

27. Are you disqualified, under the National Law or acorresponding prior Act, from applying for registration, orbeing registered, in the profession?


You MUST attach details of any disqualifications to

this application.

No

Yes

25. Have you previously had your registration cancelled,refused or suspended?


You MUST attach details of any cancellation or

refusal to this application.

No

Yes

26. Has your registration ever been subject to conditions,undertakings or limitations in Australia or overseas?


You MUST attach details of any conditions,

undertakings or limitations.

No

Yes

24. Is your registration in the profession, in Australia oroverseas, currently suspended or cancelled?


You MUST attach details of any registration

suspension or cancellation to this application.


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Registered health practitioners must inform the Board of a change in

their status in relation to the following matters within seven days after

becoming aware of that change:

the practitioner is charged with an offence punishable by 12months imprisonment or more

the practitioner is convicted of, or the subject of, a finding of guilt

for an offence punishable by imprisonment

appropriate professional indemnity insurance arrangements are

no longer in place in relation to the practitioners practice of the

profession

the practitioners right to practise at a hospital or another facility

at which health services are provided is withdrawn or restricted

because of the practitioners conduct, professional performance,

or health

the practitioners billing privileges are withdrawn or restricted

under the Medicare Australia Act 1973 of the Commonwealth

because of the practitioners conduct, professional performance,

or health

the practitioner has a restriction placed on their right to prescribe

or supply pharmaceutical benefits under the National Health Act

1953

the practitioners authority under law of a State or Territory to

administer, obtain, possess, prescribe, sell, supply, or use a

scheduled medicine or class of scheduled medicines is cancelled

or restricted

a complaint is made about the practitioner to a Commonwealth,

State, or Territory entity having functions relating to professional

services provided by health practitioners or the regulation of health

practitioners, including but not limited to:

overseas regulatory authorities

Commonwealth departments that administer Medicare

Australia; the provision of pharmaceutical, sickness and

hospital schemes; payments by way of medical benefits and

payments for hospital services; and immigration

State and Territory bodies responsible for health complaints,

workers compensation, and traffic accident investigation.

the practitioners registration, under the law of another country

that provides for the registration of health practitioners, is

suspended or cancelled or made subject to a condition or another

restriction.

SECTION G: Obligations of registered healthpractitioners

SECTION F: Details of the position

29. When will your registration period begin?

Go to next question

The date of the Boards approval

The date indicated below, being a date subsequent to the

Boards determination

Mark one box only

DD MM YYYY

31. Please read this before answering the following questionabout the position description:

Practitioners with limited registration for postgraduate

training or supervised practise must maintain their

employment in the designated position. If there is any change

to the position in which you are working you will be required to

submit a new application for registration to the Board.

30. How many months do you require the initial limitedregistration for? (maximum of 12 months)

MONTHS

You MUST attach a position description and details of the

PSDW employment scheme position including:

key selection criteria addressing clinical responsibilities;

and

qualifications and experience required (this should be

obtained from your employer).

Title of position

What is the title of the position for which limited registration is

being sought?

Note: There is a requirement to provide a completed Part B

(to be completed by the employer) before the application canbe processed.

MM


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+

SECTION H: Payment

You are required to pay both an application and a

registration fee.

Application fee

32. How are you paying your application and registration fee?

!

Go to next question

Visa or Mastercard (credit or debit card)

Go to question 34

Cheque/Money order (payable to Australian Health Practitioner

Regulation Agency )

Go to question 34Cash/EFTPOS (only available if paying in person)

Mark one box only

You MUST attach cheque or money

order.

Refund rules

The application fee is non-refundable. The registration fee will be

refunded if the application is not approved.

Fees

The fees applicable are outlined below. Registrants with a principal

place of practice in New South Wales (NSW) are eligible for an

annual registration fee rebate. Select the annual registration fee

applicable depending on your principal place of practice and

calculate the total payment amount.

Note: Payments by cheque, money order or bank draft must be inAustralian currency, drawn on an Australian bank.

Registration fee

$ =

PAYMENT AMOUNT

$

Item

Fee for annual registration

(0 - 6 months)

Fee for annual registration

(6 - 12 months)

Note: Registrants whose principal place of practice is New South Walespay the national fee less the rebate from the NSW government.

$296.00

National Fee Rebate for NSW

registrants*

Fee for NSW

registrants*

288.00

576.00

5.00

10.00

293.00

586.00

Note: If you are seeking registration for a period that is less than 6months, the registration fee that applies is 50% of the fee for annual

limited registration. If you are seeking registration for a period that is

longer than 6 months, the full fee applies.

$

Amount payable

Visa or MasterCard number

Expiry date

Cardholders name

Cardholders signature

M Y

33. Visa or MasterCard details

M Y

Visa MasterCard


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A separate sheet with your suspension or cancellation details

Question 24

A separate sheet with your cancellation, suspension or refusal

detailsQuestion 25

A separate sheet with your disqualifications details

Question 27

A separate sheet with your conditions, undertakings or

limitations details

Question 26

A separate sheet with your conduct performance or health

proceedings

Question 28

Position description and details of the PSDW employment scheme

position

Question 31

SECTION J: Checklist

A certified photocopy of your passportQuestion 3

Certified copies of all documents that provide sufficient evidence

of your identity

Question 3

A certified photocopy of your licence

Question 5

Certified copies your primary dental degree certificates

Question 11

A separate sheet with additional qualifications

Question 11

Certificate of Registration status or Certificate of Good Standing

has been requested from relevant authority

Question 12

A separate sheet with additional registration detailsQuestion 12

Evidence of successful completion of Board approved English

language test requested from relevant authority

Question 17

Your Curriculum Vitae

Question 13

A separate sheet with your criminal history and explanation of

circumstances in Australia

Question 14

A separate sheet with your criminal history and explanation of

circumstances overseas

Question 15

35. Have the following items been attached if required?

Evidence that you have actively maintained employment using

English as the primary language of practice

Question 19

A separate sheet with your impairment details

Question 23

Details which address the requirements for the recency of

practice

Question 22

SECTION I: Consent

34. PLEASE READ AND MAKE SURE YOU UNDERSTAND THISSTATEMENT BEFORE SIGNING IT:

I consent:

to the National Board and AHPRA making enquiries of

and exchanging information with the authorities of anyAustralian State or Territory, or other country, regarding

my practice as a health practitioner or otherwise

regarding matters relevant to this application

to the National Board and AHPRA making enquiries of

and exchanging information with the sponsor employer

organisation regarding matters relevant to this application.

I authorise:

the National Board to obtain my criminal history in

Australia and overseas.

I understand:

that a complete criminal history, including resolved and

unresolved charges, spent convictions, and findingsof guilt for which no conviction was recorded, will be

released to the National Board

that information will be extracted from this form and

forwarded to the CrimTrac Agency and Australian police

services for checking action, and this information may be

used by Australian police services for law enforcement

purposes including the investigation of any outstanding

criminal offences.

I acknowledge:

that the National Board may validate documents provided

in support of this application as evidence of my identity

that failure to complete all relevant sections of this

application and enclose all supporting documentation mayresult in this application not being accepted.

I undertake:

to comply with all relevant legislation, National Board

Registration Standards, Codes, and Guidelines.

I declare:

that I am aware of my infection status for blood-borne

viruses and I will comply with the requirements of the

BoardsInfection Control Guidelines

that the above statements, and the documents provided in

support of this application, are true and correct

that I am the person named in the attached documents.

I make:

this declaration in the knowledge that a false statement is

grounds for the Board to refuse registration.

I am aware:

that personal information I provide may be given to a

third party for regulatory purposes, consistent with the

National Law.

Signature of applicant Date

DD MM YYYY

Printed name of applicant


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A sponsor contact person (e.g. the name of the Human Resource

Manager/Practice Manager) and email address must be provided for

receipt of notifications.

Details of the employer sponsor (who must be a registered dentist)

must also be provided.

38. What are the details of the sponsor contact?

39. What are the details of the employer sponsor?

Name of sponsor organisation

Name of employer sponsor

Name of sponsor contact

Email address

Email address

Address

Telephone number

( )

Telephone number

( )

Suburb

State/

Territory Postcode

No. Street

Address

Suburb

State/Territory Postcode

No. Street

! PART B: TO BE COMPLETED BY EMPLOYER

SECTION K: Sponsoring employer details

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I declare:

that the information provided in this document

(including supervision and training details) is true and

correct.

I confirm:

that the applicant named below has been formally

offered the position as described in this application.

Registration Number

Signature of sponsor employer (authorised dentist)

Date

DD MM YYYY

Applicants full name


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No.

Suburb

State/

Territory Postcode

Site name

Street

Site 3

No.

Suburb

State/

Territory Postcode

Site name

Street

Site 4

SECTION M: Supervisor details

Registrants under Limited registration PSDW must meet supervision

requirements as set by the Board.

42. What are the details of the supervisor?

Name of principal supervisor

Name of co-supervisor/s (if applicable)

Registration number

Position

Email address

Registration number/s

Position/s

Telephone number

( )

Work address

Suburb

State/

Territory Postcode

No. Street

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41. What are the names and addresses of all sites of practisefor which limited registration is being sought?

SECTION L: List of sites

Provide the name and address of each site for which limited

registration is required.

No.

Suburb

State/

Territory Postcode

Site name

Street

Site 1

No.

Suburb

State/

Territory Postcode

Site name

Street

Site 2


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I undertake

to be the applicants principal supervisor and to provide

a level of supervision as determined from time to time bythe Board.

I further undertake to:

a. ensure that the applicant is practising safely and is not

placing the public at risk

b. observe the applicants work, conduct case reviews,

periodically conduct performance reviews and identify

and address any problems

c. notify the Board immediately if I have concerns about

the applicants clinical performance, health or failure tocomply with conditions or undertakings

d. inform the Board if I am no longer able to undertake the

role of the applicants supervisor.

SECTION N: Principal supervisors undertaking

Principal supervisors signature: Date

DD MM YYYY

Documents

Dental Boa rd Form Application for Limited Registration for Postgraduate Training or Supervised Practise PSDWS ALPS 20