GP TRAINEE SALARY REIMBURSEMENT FORM (1) 2016 Contract Pay set up for: General Practice (specialty) trainees who are directly employed by their practice must complete this form with their Practice Manager so that the practice receives funding via PCSE for their salary and the trainer's grant. Please note that failure to complete all sections completely will delay reimbursement. This form must be submitted to PCSE where possible at least 6 weeks before the start of the placement to allow time for payments to be set up. Section 1 General Practice (Specialty) Trainee details (to be completed by the Trainee) Forename of Surname of Specialty Trainee Specialty Trainee Date of birth GMC number Childcare voucher National Insurance amount (if £ number applicable) (annual) Are you a member Yes Are you currently Yes ……………% of the NHS Pension purchasing added scheme No years No Section 2 Practice details / correspondence address (to be completed by Practice Manager) Practice Full Name Of Address Trainer: (include Practice code: postcode) Contact email for Contact telephone queries for queries Salary and pension details (to be completed by Practice Manager) Start date of dd/mm/yy End date of dd/mm/yy placement placement Full time Yes / No Less Than Full wte …….% Time (LTFT) (please circle) Date started Date completed ST1 dd/mm/yy dd/mm/yy ST2 dd/mm/yy dd/mm/yy ST3 dd/mm/yy N/A Pay Protection For Specialty Trainees who may be eligible for pay protection under the 2016 TCS, Practices can obtain advice on assessing eligibility and calculating salary until 31st March 2018 by emailing: Does the 2016 Contract salary include Pay Protection YES NO ☐ ☐ Pay Protection Schedule 2 ☐ Pay Protection under Schedule 14 *Section 1 Pay Protection ☐ ☐
GP TRAINEE SALARY REIMBURSEMENT FORM (1) Pay set up for: 2016 Contract General Practice (specialty) trainees who are directly employed by their practice must complete this form with their Practice Manager so that the practice receives funding via PCSE for their salary and the trainer's grant. Please note that failure to complete all sections completely will delay reimbursement. This form must be submitted to PCSE where possible at least 6 weeks before the start of the placement to allow time for payments to be set up. Section 1 General Practice (Specialty) Trainee details (to be completed by the Trainee) Forename of Specialty Trainee Surname of Specialty Trainee Date of birth GMC number National Insurance number Childcare voucher amount (if applicable) (annual) £ Are you a member of the NHS Pension scheme Yes No Are you currently purchasing added years Yes ……………% No Section 2 Practice details / correspondence address (to be completed by Practice Manager) Practice Address (include postcode) Full Name Of Trainer: Practice code: Contact email for queries Contact telephone for queries Salary and pension details (to be completed by Practice Manager) Start date of placement dd/mm/yy End date of placement dd/mm/yy Full time Yes / No Less Than Full Time (LTFT) …….% wte (please circle) Date started Date completed ST1 dd/mm/yy dd/mm/yy ST2 dd/mm/yy dd/mm/yy ST3 dd/mm/yy N/A Pay Protection For Specialty Trainees who may be eligible for pay protection under the 2016 TCS, Practices can obtain advice on assessing eligibility and calculating salary until 31st March 2018 by emailing: Does the 2016 Contract salary include Pay Protection YES ☐ NO ☐ Pay Protection Schedule 2 ☐ Pay Protection under Schedule 14 ☐ *Section 1 Pay Protection ☐