LOC M VISION

WEEK ENDING DATE

AGENCY WORKER NAME
GRADE
SPECIALTY
DEPARTMENT / WARD
HOSPITAL NAME
TOTAL HOURS TOTAL HOURS
PO / REF sT*RT END BREAK
DATE Prior to break After break
NUMBER TUVIE TAKEN
deduction deduction

o IVIONDAY
TUESDAY
WEDNESDAY 211
THURSDAY
FRIDAY
SATURDAY
SUNDAY
TOTAL NOURS UI

Please can the below assessment be completed fog shifts wcrked

UNABLE TO
EXCELLENT, GOOD AVERAGE POOR
COMMENT
PHYSICAL EXAMINATIONS
\NVESTIGATION &
DIAGNOSIS
0 PATIENT MANAGEMENT &
u.' UDGEMENT
CLINICAL SKILLS
RELIABILITY

If expenses arc to bc paid the hospital, please sand along with an axponse to€rnto
TO BE COMPLETED BY THE AGENCY WORKER
By ticking this box t confirm that I have received an induction and orientation at the start of this placement.
declare that the inrormDt10'1 ; have given on thJ5focm correct hovc no: Oolmod elsewhere the dct0iied oa tiniesheea I that ir
I knowingly provide false information this may in disciplinary action and may Fable to prosecution and civil recovery proceedings. consent to the discloser of
information from this form to and by the NHS Body and the NHS Counter Fraud and Security Management Service of the purpose of verification of this c:airn and the
Investigation, prevention, detec?ion and persecution of I c.cr.firrr. i hue !nd'.r.t-ed in the proc.edur€sand that have been made
of given ail relevant access to my Gay i rights".

IGNATURE: DATE;

TO BE COMPLETED BY THE TRUST

"I am an authorised signatory got my ward/departrnent/NHS Body. I am 'igning to confirm that the above grade and specia'iry o,' the agency worker and hours/shifts
that' am authorisingere accurate and ! aoprovrzfor revrnc:nt. understand that if i authorlse intermotion tl-ds result in diuip'ina"/ action I moy he
liable for prosecution and civil recovery proceeding;. I consent to tha disc(oser of information from this form to and by the NHS Body and the NHS Counter Fraud end
Security A4enagementService (or verification of this claim and the investigation, detect;er and prosecution of fraud".

PRINT NAME:
JOB TITLE:
SIGNATURE: DATE:

GETTINGTHE TIMESHEET AUTHORiSED IS THE AGENCY WORKERS RESPONSIBILIIY. TIMESHETS SHOULD ae SENT TO
OR BY FAX 0.1908810233 BY 5PM ON TUESDAYS.