CAPR3

Expenses Claim

Application for Peer Review/Clinical Audit Project Allowances and Reimbursement of Other Permissible Expenses

This form should be completed when claiming for project expenses. Please submit your claim in Hard Copy and send to Heather Stewart at the above address.

Title of Project/Review
Completion Date
Convenor Name and Initials / Mr Mrs Miss Ms Dr Prof
Your Name and Initials / Mr Mrs Miss Ms Dr Prof
Local Health Board
Practice Phone Number / Email address
GDC Registration Number
LHB Contract Number
NHS Performer Number / Please tick if NOT an NHS Dentist

Payment Details [No payment will be made without your Diary Sheets as verification]

No of hours claimed / hours @ £65.07/hour / £ .
[Up to a maximum of 15 hours]
(N.B All NHS Contract Numbers for the duration of the audit must have been open in order to receive the maximum number of hours approved and verified by AASP)
Travel Expenses / miles @ 23p/mile / £ .
[Up to a maximum of £130 per project for distribution by Convenor]
Additional hours for Convenor / hours @ £65.07/hour / £ .
[Up to a maximum of 2.5hours can be claimed – for Convenor only]
Secretarial Support
[Up to a maximum of £110 per project for distribution by Convenor] / £ .
Total Claim
[Please ensure that you have completed the diary sheets in section IV of CAPR2] / £ .

Fees and Expenses Claim Form Declaration

I declare that (please tick boxes below)

I certify that the expenses claimed were actually and necessarily incurred by me.

I am claiming Clinical Audit Allowance and Expenses associated with the clinical audit project approved by WCAP and detailed in Annexe 1

I understand that I am liable to declare payments to the Inland Revenue and that Income Tax and NI will NOT be deducted on my behalf from the amounts claimed above.

The mileage and/or expenses were actually incurred whilst engaged on the project.

I confirm that all NHS contract numbers were open for the duration of the audit.

Signature of Claimant / Date

Verification and Payment Approval: I certify that the Wales Central Assessment Panel has determined that the above named dentist has satisfactorily completed the project above in accordance with the guidance issued by the Welsh Assembly Government and that the allowance and associated expenses detailed above are attributable to that project.

Examined & Verified by / Date

Diary Sheets Inspected CAPR2, 4 form and write up Received

Comments
Signature / Date

Director/Deputy of Dental Postgraduate Education