a&e agency timesheet
Locum Name:
Client:
Fax: 0203-137-9991
TIMESHEET Email: finance@accident-emergency.co.uk
Department:
Grade & Speciality:
Week Ending Date: / / (DD/MM/YY) Booking Ref No:
Write total number of hours
I confirm that I have worked hours
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.
Important: If you are paid as an Agency Payroll worker (PAYE), you must take your full holiday entitlement and tell us in advance when you are taking holiday. By signing below, you confirm that you understand your holiday entitlement and confirm that you have taken/will take your
full holiday entitlement before the end of the holiday year.
The signing of this timesheet will act as agreement to the terms.
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.”
Please be aware that we process your personal data based on our contract obligations and in accordance with the Data Protection Act 2018. We take data privacy and security seriously and we will not request any information that is not required for a business need. For more
information, you can find our privacy policy at https://www.accident-emergency.co.uk/terms/
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. 223 Pentonville Road, London, N1 9NG. P +44 (0) 207 456 1456 F +44 (0) 203 137 9991 E register@accident-emergency.co.uk W www.accident-emergency.co.uk
Registered in England and Wales. Registered Company No. 5927852. VAT No 902 9059 32.
Dates Shift Start Break Start*
*Please note breaks may be deducted subject to Trust Policy
Break End* Shift End Regular
Hours
On-Call
Hours
PO No - Client use
only
Breaks to be Paid –
Client to initial only
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
* Please note breaks may be deducted subject to Trust Policy Total hours:
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