Radiography Form

PERSONAL INFORMATION

Your personal information is required in order that we can properly assess your suitability for this course. Your personal data is very important to us and we will only share it with the course applicant assessors. We will take all technical and organisational measures necessary to protect your personal data in accordance with the General Data Protection Regulation, 2018 and the Data Protection Act, 2018. Your data will be retained in accordance with our data retention & destruction policy.

First name

Surname

Date of birth

Email address

Confirm email address

Telephone number (mobile)

Address 1

Address 2

Town

County

Eircode/Postcode

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 Eircode/Postcode

Work telephone number

Employer's Email address

Confirm email address

Date of commencement of employment with the above employer

Employment status

Place of employment

How many hours a week do you normally work?

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.

This dental practice uses a thyroid collar

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 UPLOAD A COPY OF THE ABOVE QUALIFICATION(S) VIA THIS ONLINE APPLICATION FORM.

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

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.

Please confirm by choosing yes, that you have discussed this programme with your Dental Practitioner and have made him/her aware of time commitment needed.

I confirm the details of the employing/supporting dental practitioner declared in the application documents are correct and will be valid up to and including commencement of the programme..

I confirm that I understand that eligibility to complete this programme is based on the confirmed support of the employing /supporting dental practitioner and details in the Access to Equipment declared in the application. If I change employer and place of employment, the details stated in the application become invalid and the offer/place on the programme may be withdrawn.

It is important that page 2 of the Supporting Documentation (this is available at the end of the programme information page – see the 'Applications' area) is completed and submitted below.

Please scan and UPLOAD each document below. Paper applications will not be accepted.

Completed and Signed 'Practitioner Declaration of Support' (see p2 of the Supporting Documentation package, available from the programme website). Please note the supporting dental practitioner is the practitioner that is to support the student throughout the duration of the programme. PDF or JPG documents accepted. word documents not accepted.

Copy of dental nursing/hygiene qualification. PDF or JPG documents accepted. Word documents not accepted.

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 30 September it may lead to the applicant's offer and/or place being withdrawn from the programme. PDF or JPG documents accepted. Word documents not accepted.

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

Tick each box below to confirm:

I understand that my application is not complete and WILL NOT BE REVIEWED, until i) the online application form is completed in full, ii) the administration fee is paid and iii) a copy of each of the above documents are supplied to the Dublin Dental University Hospital via this online form.

If successful at the first stage of the application process and as a condition of a place on the programme, I understand that I must provide a laboratory copy of the following blood tests:

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 10mIU/mL