Nursing Timesheet

Consultant Name:

Candidate Name:

Reporting to:

Job Title:

Band / Grade:

Name of Trust / Hospital:

Ward / Department:

Please Use 24 hour clock

Total Hours

Worked

Clinical/Character Assessment

Please complete:

G: Good

S: Satisfactory

U: Unsatisfactory

Would you be prepared to have this healthcare worker back in the Ward/Dept.?

Would you be prepared to have this healthcare worker back in the Ward/Dept.?

To be completed by Head of Department/Authorised Signatory

TO BE READ BY ALL CLIENTS:

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 NHS Protect (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. 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 40 60 or email nhsfraud@nhsprotect.gsi.gov.uk.

Signature

Print Name

Position

Date

Declaration: We confirm that the hours and grade/band 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.

To be completed by Agency Worker

TO BE READ BY ALL CANDIDATES:

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 NHS Protect (NHS CFSMS) for the purpose of verification of this claim and the investigation, prevention, detection and prosecution of fraud. I also declare that any travel and subsistence costs I have claimed have been necessarily incurred in the performance of my duties or travelling in order to perform my duties with Your World Recruitment Group at a temporary workplace. I also declare that any laundry costs I have claimed have been incurred by me wholly, exclusively and necessarily in the performance of my duties.

Candidate Name

Signature

Date

Declaration: I confirm I have worked the above hours. In addition, I declare that any travel and subsistence costs I have been necessarily incurred in the performance of my duties or travelling to perform my duties with Your World Recruitment Group at a temporary workplace. I also declare that any laundry costs I have claimed have been incurred by me wholly, exclusively and necessarily in the performance of my duties.