PERSONALINFORMATION(PleasecompleteinBLOCK CAPITALS)

First Name

Hospital/ Trust

707HighRoad |FinchleyHouse| Finchley|London|N120BT

Tel: 02084454102|Mobile: 07481

477397

Surname

Address

JobTitle/ Grade

TIMESHEET

Day / Date / Start Time / Start Break / Finish Break / Finish Time / Total
Hours / Dept/ Ward
(Cost Code) / BookingReference
Number / AuthorisedSignature
(for multipleapprovers) / No break taken? AuthorisedSignature
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TOTALHOURSINFIGURES / TOTALHOURSINWORDS
**Notes: (1)Toensurepayment, this Timesheet MUSTBE received by12pmTuesdayofthefollowing week
(2)Timesheets whichare not inalegibleformat or without anauthorisationsignature WILLNOTbeprocessedfor payment
(3) Timesheets without BookingReferenceand/orPOnumber (whereapplicable) WILLNOTbeprocessed

Ideclare thattheinformationI havegivenon this form iscorrectand completeand thatIhavenot claimedelsewhereforthehours/shiftsdetailedon thistimesheet.Iunderstandthat ifI knowinglyprovidefalse information thismay result indisciplinaryactionandI maybe liable toprosecutionandcivilrecoveryproceedings.I consent to thedisclosure of informationfromthis formtoandbytheNHSbodyand the NHSCFSMS for thepurpose ofverification of this claimand theinvestigation, prevention, detectionandprosecution of fraud

Locum Signature Date

TRUSTAUTHORISATION-I amanauthorizedsignatoryformyward/department/NHSbody.IamsigningtoconfirmthatboththegradeofLocumandthehours/shiftthatIamauthorisingareaccurateandIapprovepayment. I understandthatifIknowinglyprovidefalseinformationthismayresultindisciplinaryactionandImaybeliabletoprosecutionandcivilrecoveryproceedings.Iconsenttothedisclosureofinformationfromthisformtoandby the NHSbodyandthe NHSCFSMSinEngland (orNHSCFS inScotland) forthepurpose of verificationof thisclaimand the investigation, prevention,detectionandprosecutionof fraud.

AuthorisedSignature Date InductionOrientationTrainingCompleted Yes□ No□

DetailsoftheNHS Fraud andCorruptionReportingLine:Any questionabletimesheetmustbeimmediatelybroughttothe attentionoftheLocal CounterFraudSpecialist(withinEngland)oryou may reportanycase offraud,inconfidence,totheNHSFraudand

CorruptionReportingLineat08000284060(withinEngland)or08000151628(withinScotland)

PLEASEEMAILTIMESHEETWEEKLYTO:

Hens Medics