Doctor Timesheet
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1th
4
floor
1 Belle Vue Square
Broughton Road
Skipton
BD23 1FJ
Tel: 0208 099 6943
Fax: 01756 601344
Doctors full name:
Grade
Speciality
Location
Hospital name:
Date
Start Time
Finish Time
Breaks
Hours Worked
Total Hours Worked:
Trust Break Policy: 30mins/shift
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 this NHS body and the NHS CFSMS for the purpose of verification of this claim and
the investigation, prevention, detection and prosecution of fraud.
I confirm I received induction and orientation at the start of this locum/have previously received
induction/orientation at this hospital within the past year.
YES
NO
If YES, please provide date of induction ___________________
Signed:
______________________
Date:
All authorised timesheets need to be received by close of business on a Monday to be
paid by the Friday.
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 CFSMS in
England (or NHS CFS in Scotland) for the purpose of verification of this claim and the investigation, prevention,
detection and prosecution of fraud.
Signed:
____ Date: __________________
Name (caps): _____________________________________________________________
Position (caps): ____________________________________________________________
********** This timesheet must be authorised by a Consultant **********
Any questionable timesheet must be immediately brought to the attention of the Local Counter Fraud Specialist (within
England) or you may report any case of fraud, in confidence, to the NHS Fraud and Corruption Reporting Line on 0800
028 4060 (within England) or 0800 015 1628 (within Scotland)
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