A/L Entitlement (for Term Time & Annualised Hours Contracts Only)
The purpose of this form is tonotify us that the 5 or 10 year benchmark has been reached. You only need to complete this form if the employee holds a Term Time or Annualised Hours Contract. A copy of this form should be signed by the employee and held on the local personnel file as a formal record of varying the contract of employment.
*Employee Name:
*Assignment Number:
*Directorate:Team:
*Effective Date:
*Change Description: / *Current Details:*Agreed Working Hours / Sessions / PLEASE CHOOSE TYPEHoursSessions
*Annual Leave Benchmark / PLEASE CHOOSE TYPE5 Years Service10 Years Service
*Contract Type
(Please advise us using the drop-down menu if this change relates to hours or sessions that are standard, term time or annualised) / PLEASE CHOOSE TYPEAnnualised HoursTerm Time Only
*Authorisation: (This section must be signed by Authorised Signatory or copied to them in the email authorisation; the Line Managers details must also be provided to ensure records are up to date). Please tick this box to confirm this action:
Line Manager Name: / Authorised Signatory Name:
Line Manager Job Title: / Authorised Signatory Signature:
Contact Number: (in case of query) / Date:
Employee Agreement: (Please Read)
I acknowledge and accept the changes to my terms and conditions as outlined above. I have retained a copy of this form as confirmation of the change(s) and agree to check my payslip after the effective date of change reported on this form, in order to check all changes have been applied correctly. I understand that it is my responsibility to report any anomalies to the Payroll Helpdesk (0300 123 1144) and my Line Manager immediately. I understand that any overpayments will be recovered in line with Trust Policy.
Employee Name: (Please Print)
Employee Signature: / Date:
HR USE ONLY
If any additional information has been sent with this form or is requested and received at a later date please ensure you print this and store with the form to comply with audit processes.
Actioned By: / Signature:
Date Actioned in ESR: / Date No Action Required:
Please tick to confirm the following actions:
I have checked my work in ESR and have ensured that any changes linked to this change have been received/actioned.
I have updated the database with all relevant information.
I have taken any preventative measures possible to prevent overpayment.
I have requested any appropriate pay process including, single line retro, retry and sup run processing.
Audit Compliance Checks:
Checked By: / Signature:
Date:
Have Inaccuracies Been Identified? / Yes: / No:
If yes, please tick to confirm that you have completed a Yellow Form and stapled to this document as a Formal Record of the check/actions taken.
Has this form been checked by a Manager as part of formal compliance checking? / Yes: / No:
Name: / Date:
Signature:
Please return Fully Completed/Authorised forms via nhs.net to
Forms can be downloaded from:
16/11/2017 Version 2
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