Claim Form B - Induction and Refresher Placement Form

This form is to be completed by the I&R doctor and verified by the practice to
certify hours worked.
I&R Doctor
Name:

GP Practice
Name:

Address:

Supervisor/Trai
ner:

DATE(S)

Please ensure that the hours of work are recorded accurately below:
Week 1

Week 2

Week 3

Monday
Tuesday
Wednesday
Thursday
Friday
We certify that the totals hours worked are correct

Supervisor/Training Manager Signature:

Date:

Claim Form B
Created on: 28/9/2015 10.18
Created by: V Johnson & K Patel

Week 4

I&R Doctor Signature:

Date:

Claim Form B
Created on: 28/9/2015 10.18
Created by: V Johnson & K Patel