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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*
Page 1 of 13
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
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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
State/Territory/Country
2 Additional registration
DD MM YYYY
Period of registration
DD MM YYYYto
Attach a separate sheet if all your registration history does not
fit within the spaces provided.
State/Territory/Country
3 Additional registration
DD MM YYYY
Period of registration
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
Page 5 of 13
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
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
Go to the next question
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?
Go to the next question
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
Go to the next question
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
Go to the next question
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.
Go to the next question
No
Yes
Do you have an impairment that detrimentally affects or is likely
to detrimentally affect your capacity to practise the profession?
Go to the next question
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?
Go to the next question
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?
Go to the next question
You MUST attach details of any disqualifications to
this application.
No
Yes
25. Have you previously had your registration cancelled,refused or suspended?
Go to the next question
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?
Go to the next question
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?
Go to the next question
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
Page 11 of 13
40. PLEASE READ AND MAKE SURE YOU UNDERSTAND THISSTATEMENT BEFORE SIGNING IT:
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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43. PLEASE READ AND MAKE SURE YOU UNDERSTAND THISSTATEMENT BEFORE SIGNING IT:
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
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