1. PERSONAL DETAILS

Name of Examiner: / Session: 2015-2016
Examiner Address:
Email Address: / Examiner’s Institution:
Date of Birth: / Sex: Male / Female / National Insurance No:

If part or all of your claim is for the Taught element (eg Exam Board) please complete this section:

  1. REPORT

Please tick oneof the following statements as appropriate:
I enclose my report with this claim
I have already forwarded my report to……………………………………………………………………………….
I expect to forward my report at a later date. Please refund my expenses now and send me a further form with which to claim any further expenses and my fee when I submit my report.

If part or all of your claim is for aViva please complete this section:

Name of Candidate: / Candidate’s Reg No:
Name of Candidate: / Candidate’s Reg No:
Name of Candidate: / Candidate’s Reg No:
Name of Candidate: / Candidate’s Reg No:
Name of Candidate: / Candidate’s Reg No:
  1. PAYMENT DETAILS – PLEASE COMPLETE IN ALL CASES
    (Payments will be made direct into your Bank/Building Society Account)

UK ACCOUNTS
Account Name:
Bank/Building Society Name:
Roll Number: / Full Address of Branch:
Sort Code: / Account No:
OVERSEAS ACCOUNTS
Full Name and Address of Bank:
Account Name:
Bank Name: / Account No:
Sort Code: / Bank Code No:
(eg. ABA routine code: Canadian transit, BSB)
IBAN No:
(Compulsory for all EU bank accounts) / SWIFT No/BIC No/SORT CODE:
D.TRAVEL EXPENSESPlease state the type of expenses you are claiming AND indication in the V / EB / J column whether expense incurred while visiting for a Viva only, an Exam Board only, or for Joint Viva/Exam Board
TRAVEL EXPENSES
DATE / FROM / TO / COST / V / EB / J
CAR/MILEAGE EXPENSES
DATE / FROM / TO / NO. MILES / TOTAL COST
(40p per mile) / V / EB / J
ACCOMMODATION EXPENSES
DATE / PLACE / NO. NIGHTS / COST / V / EB / J
SUBSISTENCE EXPENSES
DATE / ITEM(S) / COST / V / EB / J
Total Expenses Claimed / £
E. DATA COLLECTING
From 1 August 2003 the higher education sector’s reporting body, The Higher Education Statistics Agency (HESA), extended their reporting responsibility to include individuals who do not hold typical contracts The range of data required is limited, although it does include some equal opportunities information. To enable the University to meet its reporting requirements, it is necessary to record the data for all External claimants and it is important that you complete the information below. This information will be treated in the strictest confidence and will be used for statistical analysis only.
Country of Nationality: ……………………………………………………………………………………………………………
Ethnic Origin Category (See codes): ………………
White-British 11 / White-Irish 12 / Gypsy or Traveller 15 / White-any other 19 / Black-Caribbean 21 / Black-African 22 / Black-any other 29 / Asian-Indian 31 / Asian-Pakistani 32 / Asian-Bangladeshi 33 / Chinese 34 / Asian-any other 39 / Mixed-White & Black Caribbean 41 / Mixed-White & Black African 42 / Mixed-White & Asian 43 / Mixed-any other 49 / Arab 50 / Any other ethnic group 80
Do you consider yourself to be a disabled person?: Yes …………No……………
F. ELIGIBILITY TO WORK IN THE UK (signature required)
To enable the University to meet its statutory requirements under the Immigration, Asylum and Nationality Act 2006, please confirm below that your eligibility to work in the UK has been checked.
I certify that I have provided evidence of my eligibility to work in the UK to the University of Sheffield.
Signature of claimant …………………………………………………… Date ……………………………………………..
G. TOTAL EXPENSES CLAIMED(signature required)
Please check to confirm that the bank details you have provided are those of your personal account ……………
I certify that all expenditure was wholly, necessarily and exclusively incurred while examining for the above-mentioned degree.
Signature of claimant …………………………………………………………… Date ………………………….………………………..
Please return the completed form, with original receipts to: Rebecca Swift and Eve Grant, Learning and Teaching Services, The University of Sheffield, Ground Floor, New Spring House, 231 Glossop Road, Sheffield, S10 2GW )
H. INCOME TAX INFORMATION – YOUR PRESENT CIRCUMSTANCES Please enter X in the appropriate box
This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance, Employment Support Allowance or taxable Incapacity Benefit or a state or occupational pension
This is my only job, but since last 6 April I have had another job or have received taxable Jobseeker’s Allowance, Employment and support Allowance or taxable Incapacity Benefit. I do not receive a state or occupational pension.
I have another job or receive a state or occupational pension
FOR OFFICE USE ONLY
Fee: £ / 302652.3407 / Exp: £ / 305330.3432
Authorised Signatory / As Authorised Signatory I confirm that the fee level is correct, funding is available and that the work has been effectively undertaken and satisfactorily completed.