the Timesheet here. - Corrigan`s Door Locum Agency

the Timesheet here. - Corrigan`s Door Locum Agency

HEAD OFFICE: 15 Devonshire Mews, Chiswick, London W4 2HA
TEL: 0208 994 6862
FAX: 0208 994 6863
Doctor’s Name:
_______________________________________
Hospital:
_______________________________________
Department:
_______________________________________
Grade & Specialty:
_______________________________________
DAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
DATE
START TIME
FINISH TIME
TOTAL HOURS
TOTAL HOURS FOR WEEK:
Counter fraud declaration to be signed and dated by the LOCUM DOCTOR : “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 client hospital/NHS Body for the purpose of verification of this claim and
the investigation, prevention, detection and prosecution of fraud.”
Signature: _____________________________ Date: ____________________________________
Counter fraud declaration to be signed, with printed name and position of the AUTHORSISED SIGNATORY, and dated
by the Authorised Signatory of the client hospital (and cost centre stamp if required by the client hospital) “I am an
Authorised Signatory for my ward/department/client hospital/NHS Body. I am signing to confirm that both the grade of Locum Doctor 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
the client hospital/NHS body for the purpose of verification of this claim and the investigation, prevention, detection and prosecution of fraud.”
Name: ________________________________ Position: _________________________________
Signature: ____________________________ Date: ____________________________________
Induction/Orientation Declaration to be signed and dated by the LOCUM DOCTOR: “I declare that I have worked through the
Corrigan’s Door Induction and Orientation Checklist with a permanent member of the Hospital’s staff and have been made familiar with the
Hospital and all the necessary policies and procedures:
Medical Locum Signature: _____________________________ Date:_________________
Induction/Orientation Declaration to be signed and dated by the Authorised Signatory: “I declare that I am a permanent
member of the Hospital’s Staff and I have worked through the Corrigan’s Door Induction and Orientation Checklist with the Locum Doctor and
have him/her familiar with the Hospital and all necessary policies and procedures:
Authorised Signatory: _____________________________ Date:_____________________
Corrigan’s Door Ltd. Registered in England No. 4314299. Registered Office: 6D Ocean House, Bentley Way, New Barnet, Hertfordshire EN5 5FP
HEAD OFFICE: 15 Devonshire Mews, Chiswick, London W4 2HA
TEL: 0208 994 6862
FAX: 0208 994 6863
CORRIGAN’S DOOR LTD END OF PLACEMENT ASSESSMENT FORM
NAME OF DOCTOR:
HOSPITAL:
GRADE COVERED:
SPECIALTY COVERED:
ASSIGNMENT START DATE:
ASSIGNMENT END DATE:
0
1
2
3
4
Excellent
Very Good
Good
Satisfactory
Please  as appropriate, providing additional comments in
support of the statements made
Poor
Unable to
comment
As part of the Medical Locum’s Revalidation process it is a requirement for the Trust/Hospital to complete
and return this form to Corrigan’s Door Ltd either by Email: [email protected] or FAX: 0208 994
6863 . We would like to thank you for taking the time to complete this form, as it plays a VITAL part in the
ongoing assessment of the performance of the doctor. If you would like to discuss any aspect of the form in
confidence, please feel free to contact Suzanna Nuthall, Director, Corrigan’s Door Ltd TEL: 0208 566 0268
5
Clinical skills demonstrated in line with the requirements
of the grade and specialty of the position
Relationships with patients, other healthcare workers and
the public/patient’s families
Management of workload
Maintaining patients’ notes and other records
Timekeeping and Reliability
Communication skills – written and spoken English
Supervisory skills
Organisational skills and time management
Sickness/absence record - relevant for long term assignments only
Additional comments in support of the statements made above:
I confirm that I am an authorised signatory of the Hospital/Trust.
Signed:
Date:
Print Name:
Position:
Corrigan’s Door Ltd. Registered in England No. 4314299. Registered Office: 6D Ocean House, Bentley Way, New Barnet, Hertfordshire EN5 5FP