INVOICE

ALL FORMS MUST BE TYPED AND NOT HAND WRITTEN. THEY MUST ALSO BE COMPLETED IN FULL. FAILURE TO DO THIS WILL RESULT IN PAYMENT DELAYS OR NON PAYMENT

For HEKSS Use Only

Invoice Number / 17ASK533 - FY2 -
Invoice Date / / / /
PO Number / XXABOGAARS
Practice Name / FAO
Address Line 1
Address Line 2 /
Address Line 3
Town/City
Post Code
Health Education England – T73
KSS LETB
T73 Payables F485
Phoenix House
Topcliffe Lane
Tingley
Wakefield
WF3 1WE
Bank Account Number / Sort Code / Payable to (practice account) / Swift code
(overseas only) / E-mail address for
remittance advice

NOTE: PLEASE ENSURE BANK DETAILS ARE ENTERED. FAILURE TO ENTER THESE DETAILS WILL RESULT IN THE REMITTANCE BEING MADE BY CHEQUE, WITH INEVITABLE PAYMENT DELAYS.

Total Value of the Claim / £ 2,583.67

Please fill in the breakdown of the claim on the following page

Details of the claim

Travel Expenses / N/A
Start Location: N/A / Finish Location:N/A
Public Transport / Mode of transport:
(Receipts must be attached) / £ N/A
Private Transport / Total Number of Miles:______@ 24p per mile
(Mileage will be calculated at quickest route) / £ N/A
Passengers
(Reimbursed at 5p per mile per passenger) / Name(s) of passenger(s):______
Total miles travelled with passenger ______
(Passengers must be travelling to same event & also entitled to reimbursement of travel expenses by HEKSS) / £ N/A
DETAILS OF CLAIM (ALL CLAIMS MUST BE ACCOMPANIED BY RECEIPTS)
Where there is no receipt a full written explanation must be attached
Please read the guidance notes you obtained along with this claim form very carefully.
HEKSS reserves the right to reimburse the cheapest option wherever relevant.
EVENT/ACTIVITY / FY2 Clinical Supervisor – Tutorial & Supervision Grant
NAME OF FY2 CLINICAL SUPERVISOR
NAME OF FY2 TRAINEE DOCTOR
CLAIM PERIOD / TO
Resource Fee / Backfill / Course Fee / Amount Claimed
Resource Fee /Backfill Payment/Course Fee / £2583.67
Claimant Declaration: I declare that the expenses claimed hereunder were necessarily incurred by me in providing clinical supervision and FY2 tutorials in accordance with the conditions governing the payment of travelling expenses attached. I understand that any fees are paid gross and that I am responsible, where appropriate, for declaring this income for tax purposes.
Name:
Signed: Date:
Certification of Attendance: I have checked this claim and am satisfied that the claimant attended the event according to the information given and that the Total claimed is correct.
Name:
Signed: Date:

This form then needs to be returned to the LETB for authorisation before submission to SBS

Authorised By:
Name:
Position:
Department:
Contact Number:
Signed: Date:

HEE KSS GP School

GP Clinical SupervisorService Level Agreement

Please print 1 copy in BLOCK CAPITALS and return TOGETHER with claim form to:

GP Educator Pathway Manager, HEE KSS, Stewart House, 32 Russell Square, London, WC1B 5DN

Name of FY2 GP Clinical Supervisor
Name of FY2 Trainee Doctor
Is the FY2 NHS or MOD (Army)? / NHS / MOD
Dates FY2 Trainee In Practice / From / To
Practice Address
Telephone Number (Practice)
Clinical Supervisor Email Address
FY2 Email Address
Practice Manager / Name:
Telephone Number:
Email Address:

I confirm that I have been through the HEE KSS Clinical Supervisor training and am approved as a GP Clinical Supervisor, and I confirm that the Practice has been approved for this purpose (and will be re-approved as appropriate).

  • I have been informed of what is required of a CS which includes providing a weekly inhouse tutorial for the FY2 doctor and am aware of the guidance and regulations contained in the Practical Guide to the Foundation Programme and that an honorary contract (Appendix 4) will be signed between the FY2 and myself.
  • I confirm I have been trained and am up to date in Equal Opportunities legislation and, that I am required to undertake the on-line training arranged by HEE KSS , and that training is valid for three years. The date of my most recent EO training is …….…/……………/…………...
  • I confirm that I will continue my development as an educator with the support of my peers and the local Programme Directors attending regular learning and GP Trainer meetings. In addition completing the required ETFT modules for GP.I undertake to inform HEE KSS immediately of any circumstances that may interfere with my ability to discharge my role appropriately.
  • I am aware of the HEE KSSsupport network for the Foundation Programme locally and will involve this if I have any educational or clinical concerns at any stage about the trainee doctor.
  • If I decide to withdraw as a Clinical Supervisor I will notify the local GP Programme Director and the HEE KSS in writing with a minimum of one month’s notice before the trainee placement commences.
  • I will encourage the FY2 to complete the FY2 end of training placement on-line survey (which will be circulated directly to the FY2 HEE KSS).

I understand that I will claim payment for this by submitting a completed claim form at the beginning of each 4-month placement period.33.33% of the GP Trainer grant will be paid as a pro-rata allowance (currently £7,751per year)

Signed:

…………………………………………………………. FY2 Clinical SupervisorDate: …………….

…………………………………………………………. KSS GPDean Date ….………….

A copy of this SLA contract should be completed and signed at commencement of the attachment and sent (within 4 weeks of the start date) to the GP Educator Pathway Manager, HEE KSS, Stewart House, 32 Russell Square, London, WC1B 5DN.One copy of this SLA will then be signed by the GP Dean and returned to you for your records.