Certificate in Dental Radiography Application Form Original

PERSONAL INFORMATION

First name

Surname

Date of birth

Email address

Confirm email address

Telephone number (mobile)

Telephone number (home)

Address 1

Address 2

Town

County

Post Code

EMPLOYER DETAILS

Name of current employer (first name and surname of supervising dentist)

Employer's Address 1

Employer's Address 2

Employer's Town

Employer's County

Employer's Post Code

Work telephone number

Employer's Email address

Confirm email address

Date of commencement of employment with the above employer

Employment status

How many hours a week do you normally work?

Place of employment

ACCESS TO EQUIPMENT

Please ask your employer to assist you in completing this important section.

This dental practice uses:

Conventional film

Direct digital sensors

Charge-Coupled Device (CCD)

Photostimulable Phosphor Storage Plates (PSP)

Rectangular collimation is/will be used on all intra-oral radiographic equipment in this dental practice.

Occlusal view image receptors (76mm x 57mm) are available in this dental practice.

Circular collimation is/will be used on all intra-oral radiographic equipment in this dental practice.

The following image receptor holders are/will be used in this dental practice for paralleling technique periapical images and for bitewing images.

Rinn holders

Kerr Hawe Neos holders

Other

Which of the following equipment do you have in your dental practice?

Intra-oral x-ray machine

OPG machine

Lateral ceph

The "practitioner in charge" of this dental practice will arrange for me to expose at least 10 panoramic (OPG) radiographs.

The "practitioner in charge" of this dental practice will arrange for me to expose at least 2 lateral cephalometric radiographs.

The "practitioner in charge" of this dental practice will arrange for me to expose at least 15 bitewing radiographs.

The "practitioner in charge" of this dental practice will arrange for me to expose at least 20 periapical radiographs.

The "practitioner in charge" of this dental practice will arrange for me to expose at least 15 other exposure radiographs.

DENTAL NURSING / DENTAL HYGIENE EDUCATION

Please provide details of your dental nursing and / or dental hygiene qualification. Please provide details of your dental nursing and / or dental hygiene qualification, including:

Name of the programme
Award received
Date of qualification

IN ORDER TO COMPLETE THIS APPLICATION YOU MUST SEND US A PHOTOCOPY (NO ORIGINALS) OF THE ABOVE QUALIFICATION(S) BY EMAIL TOGETHER WITH THE REST OF YOUR APPLICATION

Are you registered with the Dental Council of Ireland? (you must be registered to be eligible for this programme).

Do you have any special needs? (learning, medical or physical difficulties that we would need to be aware of)

ADDITIONAL INFORMATION

Using this space, please tell us why you should be considered for a place on this programme.

How did you hear about this programme?

Practitioner

Previous graduate

Journal of the Irish Dental Association

Irish Dental Nurses Association

Other journal or magazine

Other

What device(s) will you be using (tick all that apply)

Laptop / PC

Ipad

Android tablet

DECLARATION

I certify that the information provided in this application form is accurate and true to the best of my knowledge. I understand that providing incomplete or false information may result in my application not being processed.

I understand that this programme is based online and I must have access to a computer and internet access (high speed or broadband) to enable daily access to the programme website.

Please confirm by choosing yes, that you have read and understood the Application Process and Course Outline document. This is posted on the front page.

Tick each box below to confirm that you understand your application is not complete, and will not be reviewed, until the non-refundable application fee is paid and a copy of each of the below are supplied by email to the Dublin Dental University Hospital. Please ensure the Supporting Documentation pack is completed and submitted as below (this is available from the programme webpage). Please send all correspondence by email to:DentalNurseTutor@dental.tcd.ie.

Payment of €40 non-refundable administration fee by electronic transfer with proof of payment sent to email: DentalNurseTutor@dental.tcd.ie. See Application Process and Course Outline document for bank details.

Proof of non-infection with Hepatitis B. This must be dated within 6 months.

Proof of non-infection with Hepatitis C. This must be dated within 6 months.

Proof of Hepatitis B immunity. The result must be greater than 100mIU/mL.

COPY of your dental nursing/dental hygiene qualification

COPY of proof of current registration with the Dental Council of Ireland for period up to 31st August of this year or proof of renewal/new registration certificate for 1st September this year (receipts of online payment will be accepted until the submission of the registration certificate for 1st September onwards). If there is no submission of the copy of this registration certificate by Friday 30 September it may lead to the applicant's offer and/or place being withdrawn from the programme.

COPY of all the pages of your current licence of radiography equipment in your dental surgery (and associated conditions if applicable)

Signed practitioner declaration of support (this document is included in the supporting documentation package, availablefrom the programme webpage.

Please review documentation before submitting