sensible staffing timesheet
Working hours:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Date Booking Ref Start Time Finish Time Break Overtime Worked
Hours
On Call
Hours
Combined
Hours
Total Hours
Daily Authorised Signature for Worked Hours
SENSIBLESTAFFING Timesheet
Agency Worker
Signature:
x Date:
Agency Worker declaration: 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 CFSMS for the
purpose of verication of this claim and the investigation, prevention, detection and prosecution of fraud. I declare that I am t to work & that I will
promptly inform the Company if this does or is likely to change. I have received an induction and orientation by the Client for this assignment, including
details of any onsite health & safety requirements and I have access to personal protective equipment. I conrm that I have not worked for this Client via
another employment business within the previous twelve calendar weeks and that I am responsible for monitoring my hours of work in relation to the
Working Time Regulations. I have read, understood and agree to the Terms of Engagement supplied to me by the Company.
Agency Worker Details:
Forename(s):
Surname:
Grade:
Speciality: Placement Code:
Client Name:
Client Site:
Client Dept:
experts in healthcare recruitment
Weekly Hours Authorised by the Client: CLIENT SECTION ONLY
Placement assessment. Please as
appropriate.
Clinical skills in line with needs of position
Relationships with patients & sta
Timekeeping
Managing workload
Reliability
Communication skills
Supervisory skills
Organisational ability
Sickness/absence record
Overall clinical & professionals performance
N/A Unsatisfactory Borderline Satisfactory Good Excellent
Client declaration: I am an authorised signatory for my ward/department/Company/NHS body. I am signing to conrm that the
Job Title and Band (where applicable) of the 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 for the purpose of verication of this claim and the investigation, prevention,
detection and prosecution of fraud. I acknowledge that the standard terms of business or other terms of business as stated on
the Conrmation of Booking have been made available to me and are accepted and that an introduction fee may be chargeable
should a transfer of the Agency Worker either to direct/permanent employment or engagement by a third party occur.
NHS Fraud & Corruption Line: Any questionable timesheet must be immediately brought to the attention of the Local Counter
Fraud Specialist or you must report any case of fraud in condence to the NHS Fraud and Corruption Reporting Line on 0800
028 4060 (within England) or 0800 015 1628 (within Scotland).
Print Name:
Client Signature: x
Position:
Date:
On completion, please fax to: 0208 364 9966 or email to: timesheets@sensible-sta‑ng.com Page 1 of 1
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