Timesheet Template printable pdf download

Fax: 0203-137-9991

TIMESHEET

Email: finance@accident-emergency.co.uk

Locum Name:

Department:

Client:

Grade & Speciality:

Week Ending Date:

(DD/MM/YY)

Booking Ref No:

Breaks to be Paid –

Travel Expenses:

PO No - Client use

Dates

Shift Start

Break Start*

Break End*

Shift End

Regular

On-Call

Business

Personal

Client to initial only

only

Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

* Please note breaks may be deducted subject to Trust Policy

Total hours:

Total

It must be assumed that travel is not paid unless authorised by

the A&E Agency at time of booking. Transport receipts must be

Write total number of hours

sent with travel claims. Standard mileage is paid at 23 pence per

I confirm that I have worked

hours

mile

Note: Any questionable timesheet must be immediately brought to the attention of the Local Counter Fraud Specialist or you may report any case of fraud, in confidence, to the NHS Fraud and Corruption Reporting Line on 0800 028 4060.

“I declare that the information I have given on this form is correct and complete and that I have not claimed elsewhere for the hours/shifts detailed on this timesheet. I understand that if I knowingly provide false information this may result in disciplinary action and I may be liable to

prosecution and civil recovery proceedings. I consent to the disclosure of information from this form to and by the NHS body and the NHS Counter Fraud and Security Management Service for the purpose of verification of this claim and the investigation, prevention, detection

and prosecution of fraud. I confirm that I have been inducted in line with the trust local procedures and policies and that I have been made aware of and given all relevant access to my Day 1 rights.”



PLEASE TICK THIS BOX TO CONFIRM YOU AGREE WITH THE LAST STATEMENT:

LOCUM DOCTOR SIGNATURE:

PRINT NAME:

“I am an authorised signatory for my ward/department/NHS body. I am signing to confirm that both the grade of Agency Worker and the hours/shift that I am authorising are accurate and I approve payment. I understand that if I knowingly provide false information this may result in

disciplinary action and I may be liable to prosecution and civil recovery proceedings. I consent to the disclosure of information from this form to and by the NHS body and the NHS Counter Fraud and Security Management Service for the purpose of verification of this claim

and the investigation, prevention, detection and prosecution of fraud. I confirm that the above mentioned doctor has been made aware of all our trust policies and procedures and has been inducted accordingly, we have also made them aware of their Day 1 rights and given them the

relevant access.”

Authorisation: We confirm the hours and grade shown on this timesheet have been worked to our satisfaction and that this will form the basis of an invoice which will be paid on receipt. We agree to be bound by the terms and conditions of business.

The timesheet is invalid without this signature:

CLIENT SIGNATURE:

PRINT NAME:

Accident & Emergency Agency Limited. First Floor, 5 Devonshire Square, London, EC2M 4YD. * P +44 (0) 207 456 1456 F +44 (0) 203 137 9991 E

* Registered in England and

Wales. Registered Company No. 5927852. VAT No 902 9059 32.