TRAVEL AND EXPENSES POLICY & PROCEDURE

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1 TRAVEL AND EXPENSES POLICY & PROCEDURE Document Owner Document Author Helen Edmondson Jenny Ambrose Hayley Byrne Anne Ephgrave Version 1.0 Directorate Human Resources Authorised By Executive Team Date of Approval 25 th July 2013 Date of Review 25 th July 2015 Change History Version Date Name Revision Description 0.1 Draft July 2013 Jenny Ambrose Hayley Byrne Anne Ephgrave Reviewed and amended for ENHCCG 0.2 Draft September 2013 Julie Andrews Quality assured 1.0 Final To be reviewed: This policy will be reviewed after 2 years, or when the relevant national guidance on which it is based is amended. This is an East and North Hertfordshire Clinical Commissioning Group (ENHCCG) Policy but will be implemented and used in conjunction with other CCG policies. Page 1 of 19

2 Contents Section No. Section Name Page No. Executive Summary 3 1. Introduction 4 2. Terms / Acronyms Used 4 3. Scope and Purpose of the Policy 4 4. Administration 5 5. Risk Assessment 5 6. Drivers of Personally Owned Vehicles 6 7. Mileage Rates 7 8. Excess Travel 7 9. Passengers Journeys between Home and Permanent Place of Employment, Base or Places Visited 11. Other travel Other Related Allowances Subsistence Allowances Completion and Submission of Claims Responsibilities of Certifying Officers Interview Expenses Monitoring Compliance and Effectiveness Interpretation References Related Polices and Documents 12 7 Appendix 1 Appendix 2 Appendix 3 Guidance Notes for staff and Managers on Excess Travel Payments How to calculate Mileage Equality Impact Assessment Stage 1 Screening Appendix 4 Privacy Impact Assessment Stage 1 Screening Page 2 of 19

3 Executive Summary This document explains East and North Hertfordshire Clinical Commissioning Group (hereafter referred to as the CCG) s Travel and Expense Policy, together with procedural guidance for all staff when completing and submitting claims. The CCG recognises that many of its employees are required to travel in the course of their work. This document details how the organisation will reasonably reimburse travel and other expenses paid out by staff and those who are out of pocket whilst on business for the organisation. The policy seeks to ensure that all staff know how to claim reimbursement for expenditure they have necessarily incurred during the course of their work. It sets out the duty placed upon staff to ensure any claims they make are accurate and legitimate. Line managers must be conversant with this policy, ensure that their staff are aware of it and comply with its requirements. This policy and procedure reflect the rules of the NHS Terms and Conditions of Service Handbook (Agenda for Change) Section 17 which deals with mileage allowances and Section 18 which covers subsistence allowances. The rules contained in this document deal with the conditions of service for CCG staff and are updated from time to time. They are supplemented by instructions that have been issued by the Payroll Departments which are now encompassed in this policy. This policy has been fraud tested by CCG s Local Counter Fraud Specialist. Page 3 of 19

4 1. Introduction 1.1. The CCG is committed to being an organisation within which diversity, equality and human rights are valued. We will not discriminate either directly or indirectly and will not tolerate harassment or victimisation in relation to gender, marital status (including civil partnership), gender reassignment, disability, race, age, sexual orientation, religion or belief, trade union membership, status as a fixed-term or part-time worker, socio - economic status and pregnancy or maternity The CCG works to a framework for handling personal information in a confidential and secure manner to meet ethical and quality standards. This enables National Health Service organisations in England and individuals working within them to ensure personal information is dealt with legally, securely, effectively and efficiently to deliver the best possible care to patients and clients The CCG, via the Information Governance Toolkit, provides the means by which the NHS can assess our compliance with current legislation, Government and National guidance Information Governance covers: Data Protection & IT Security (including smart cards), Human Rights Act, Caldicott Principles, Common Law Duty of Confidentiality, Freedom of Information Regulations and Information Quality Assurance 2. Terms / Acronyms Used DVLA - The Driver and Vehicle Licensing Agency 3. Scope and Purpose of Policy 3.1. This document explains The CCG s Travel and Expense Policy, together with procedural guidance for all staff when completing and submitting claims The policy seeks to ensure that all staff know how to claim reimbursement for expenditure they have necessarily incurred during the course of their work. It sets out the duty placed upon staff to ensure any claims they make are accurate and legitimate Line managers must be conversant with this policy, ensure that their staffs are aware of it and comply with its requirements This policy and guidance apply equally to all CCG staff, including Non-Executive Directors and any persons representing or undertaking work on behalf of CCG where an agreement is in place to meet expenses The policy defines the responsibilities of Certifying Officers, which includes the requirement to confirm, so far as it is practicable to do so, that any claim is right and proper and consistent with any advance authorisation which may have been given. Page 4 of 19

5 4. Administration 4.1. Travel and expense claims are administered by the McKesson Payroll Department. All staff working for East and North Hertfordshire CCG will be able to process all their business expenses through the online Expenses Management System provided by Software Europe. To access the online system please visit For all general queries around the payment of expenses, please send an to 5. Risk Assessment 5.1. Line managers will manage the processes to minimise the risks associated with vehicle usage by CCG staff. If this monitoring indicates that actions are required by the employee, s/he must undertake the action requested, otherwise they must cease driving or using their vehicle for work purposes Prior to initial usage, all vehicles and drivers will be subject to a risk assessment by their line manager. The vehicle must be fit for purpose and suitable for the work to be undertaken. The driver must hold a current driving licence that entitles them to drive in the UK; the licence (both parts if it is a photo driving licence), should be checked on application and at least annually thereafter. If the licence expires during the year a further check is required Other documentation should be submitted initially and at any time on request including; insurance certificate and schedules, MOT certificate, Road Fund Licence Employees will not be able to submit claims until all the relevant documentation has been provided If an individual provides false documentation this will be dealt with under the relevant Disciplinary Policy and the Fraud and Anti-Bribery Policy The risk assessment will also take into account: (i) (ii) (iii) (iv) (v) (vi) (vii) Type of job and the annual business mileage expected to be travelled. The geographic location. Up to date MOT certificate, recording expiry date and confirmation that the vehicle has a valid Road Fund Licence. Employees must use safe vehicles on CCG business. Review of vehicle insurance certificate and schedules; confirming business cover and expiry date of the insurance cover. A valid driving licence indicates, at the time of application, that the driver was fit to drive. If line managers are concerned about the information provided, they should liaise with their Human Resources Manager who will consider referral to the Occupational Health Service. There are no convictions that could indicate reckless or dangerous driving. Page 5 of 19

6 (viii) (ix) Classification of driver s licence held which must cover the type of vehicle being used. Validity of any foreign driver s licence if applicable to ensure it does not expire within 1 year. 6. Drivers of Personally Owned Vehicles 6.1. Staff must obtain written approval to use their own vehicle for work purposes by completion of an official vehicle user registration form. Vehicles should not be used without having been given prior approval by their line manager and travel claims will not be paid unless an official vehicle user registration form has been received by the Payroll Department The official vehicle user registration form is available on the CCG intranet to print and complete. Classifications of registered vehicle users are contained on the vehicle user registration form and any criteria required must be met Whilst CCG will actively manage at work road risk, drivers remain responsible for their own and others safety on the road. Drivers should comply with the Road Traffic Acts and the Highway Code. Under the Health and Safety at Work Act, drivers must co-operate with the CCG in order to enable it to comply with its Health and Safety duties as an employer All privately owned vehicles should be suitable for the work undertaken and be fit for purpose. Drivers should ensure vehicles are road worthy, in good condition and carry out regular vehicle checks, paying particular attention to tyres, brakes, steering and lights. Any change in vehicle or temporary substitute should be reported to the line manager before use. The CCG reserves the right to carry out checks on any vehicle and if in the opinion of a representative of the CCG vehicle is considered unsuitable it must not be used for work Drivers should ensure that they are physically fit to drive and have regular eye tests where appropriate. Drivers should report to their line manager any illness or condition that may affect the safe driving of their vehicle Drivers are forbidden to drive any vehicle on CCG business whilst under the influence of alcohol or any controlled substance. The CCG policy on Alcohol and Substance Abuse is available on the intranet The CCG policy on the use of mobile phones is available on the intranet The insurance cover for any vehicle used should be fully comprehensive, including cover for usage on CCG business. Managers are responsible for checking employee s insurance cover on an annual basis 6.9. Drivers must hold a current driving licence which entitles them to drive in the UK. All holders of foreign driving licences should report to the DVLA and hold a provisional UK licence and take a UK test within the specified period of time Drivers have a responsibility to advise their insurance company of any change in their licence and penalty points. Drivers should similarly inform their line manager of any driving offences which may lead to the loss of their licence and affect their ability to drive on CCG business. Page 6 of 19

7 6.11. The MOT certificate and Road Fund Licence should be current and made available for inspection on request The CCG recommends that vehicle users are members of an approved breakdown and recovery service, which covers the vehicle being driven whilst at work. 7. Mileage Rates 7.1. The NHS Staff Council has introduced new arrangements for reimbursing NHS Staff who use their vehicles for work business. The two categories are abolished with only a single amount being used to reimburse staff These entitlements will be reviewed twice yearly by the NHS staff council to ensure they remain appropriate based upon cost to the member of staff The mileage rates information is available on the CCG s intranet. 8. Excess Travel 8.1. Guidance notes for managers and staff on excess travel payment are provided at Appendix Passengers 9.1. Where other employees or members of an NHS organisation are conveyed in the same vehicle on NHS or CCG business and their fares would otherwise be payable by CCG, passenger allowances shall be paid provided passenger details are supplied e.g. or letter confirmation Where two or more employees of CCG attend the same meeting, they should liaise with one another and, wherever possible, arrange to travel together. 10. Journeys between Home and Permanent Place of Employment, Base or Places Visited Staff with a permanent base will be paid the single mileage rate as appropriate. They will be reimbursed for miles travelled in the performance of their duties which are in excess of the home to agreed work base return journey. Please refer to examples in Appendix 2 for further detail. 11. Other Travel 11.1 Employees will be expected to use the most economical form or class of transport, this is usually standard class. The use of taxis would only be authorised when there is no other form of suitable transport. 12. Other Related Allowances Subject to the production of receipts, staff using their own car on CCG business shall be refunded reasonable parking costs, toll and congestion charges necessarily incurred. Page 7 of 19

8 12.2. CCG recognises that not all car parking facilities provide tickets or receipts as proof of payment, however staff should endeavour to park where such receipts are available. In the event that no alternative is possible or where cost is a factor and cheaper parking is available without a receipt, staff are to maintain a daily record of any such parking cost expenditure and provide this record to Certifying Officers when submitting claims as verification of expenditure Staff are personally liable for any excess parking charges or fines issued to them and no refunds will be provided by CCG. Similarly excess fare charges on any means of public transport are the responsibility of the traveller and not the CCG s Where, at the requirement of CCG, an employee carries heavy or bulky equipment in their own car which does not fit into the vehicle boot or is capable of being carried by hand or is so bulky as to reduce seating capacity in the vehicle, half the passenger allowance may be claimed Where a member of staff is required to return to or to attend their place of employment or base outside their normal hours of work, any expenses in excess of their normal attendance at work and which are actually and necessarily incurred in travelling to and from home will be reimbursed at the appropriate rate. Claims for expenses will not be met where no additional expenditure was incurred. 13. Subsistence Allowances Subsistence allowance is intended to reimburse employees for the necessary extra cost of meals (excluding alcohol), accommodation and travel arising as a result of CCG business away from home or permanent place of employment. In practice, most travel related to work away from home involves attendance at a conference, training event, formal visit or meeting, where meals and accommodation are often provided or included in whole or as part in any fee When a member of staff intends staying overnight on CCG business in a hotel, guesthouse or other commercial accommodation which attracts a cost, prior approval must be sought from their line manager before incurring any actual costs. Reimbursement for expenditure without prior approval will be limited to exceptional circumstances and agreed with line managers as soon as is practicable after the event. Receipts for staying overnight in commercial accommodation are always available and required to be produced to support such expenditure The CCG will reimburse overnight costs for: (i) (ii) The actual receipted cost of bed and breakfast up to the limit stated on the CCGs intranet A meals allowance to cover the cost of a main evening meal and one other day-time meal up to the limit stated on the intranet (excluding alcohol) These limits are subject to review and change and claimants should ensure they are aware of the current rate before incurring any actual costs. Page 8 of 19

9 13.5. Where any maximum limit is likely to be exceeded for genuine CCG business reasons, employees are required to obtain prior approval from their line manager Further rules for night subsistence allowances are contained within the NHS Terms and Conditions of Service Handbook and staff, line managers and Certifying Officers should check these before incurring any other costs or authorising claims for payment Where staff are absent from home on CCG business and more than five miles from their permanent place of employment a meal allowance may be payable. This allowance is only payable when an employee necessarily spends more on a meal or meals than they would have been spent at their permanent place Any staff members claiming a lunch meal allowance must be expected to be away from their base for a period of more than five hours which covers the normal lunchtime period of 12:00 pm to 2:00 pm Any staff members claiming an evening meal allowance must be expected to be away from their base for more than ten hours and unable to return to their base or home before 7:00 pm and as a result of a late return have an evening meal Where an employee is required to work late at night in addition to a day duty they may be paid an evening meal allowance but eligibility should be confirmed with their line manager before incurring any actual costs Where staff are uncertain of their eligibility to claim subsistence allowances they should check with their line manager before incurring any actual costs. 14. Completion and Submission of Claims All claims for business travel and expenses should be made via the CCG s Online Expenses system All sections of the claim should be correctly completed to enable authorisation by Certifying Officers and for Payroll Department staff to process and pay claims. This includes the details of each journey made on CCG business and the date when the journey was made; the details of each journey, including the starting point, all places visited and the final destination; the reason for the journey and the business mileage claimed Where a claimant has undertaken multiple journeys in any one day, each location visited must be entered clearly onto the claim The system calculates mileage based upon the shortest route. If the mileage travelled does not match this because the employee has had to make a detour due to road works, diversions, etc, the number of miles that the system gives can be overwritten. If this is done the employee must provide an explanation for the additional miles travelled in order that the Certifying Officer can understand the reasons for this Where claimants are claiming for conveying authorised passengers, the name of the passengers must be entered onto the system. Page 9 of 19

10 14.6. Receipts for all expenditure are, as a rule, are always required. Staff must scan their receipts and attach these to their Online Expense claim Where an employee s duties require them to book external meeting room facilities or provide refreshments and/or light snacks to public attending such a meeting, prior approval must be sought from their line manager before any expenditure. No claims are to be made for personally purchased refreshments and/or light snacks which do not meet the criteria of subsistence allowances Claims should be submitted promptly after expenditure to assist with budget forecasting. Claims older than three months will not be accepted for payment, unless exceptional circumstances exist. Claimants will be required to justify to their Certifying Officer reasons for unacceptable delay in the submission of claims Before submitting their Online expenses claimants are required to confirm that the information they are giving is correct Assistance with the Online Expenses system may be sought by sending an to 15. Responsibilities of Certifying Officers Certifying Officers must satisfy themselves fully of the veracity of claims, justification for expenditure and examine any supporting receipts, records, log books or duty forecasts before authorising claims Where any doubt exists as to the veracity of claims, Certifying Officers should confirm all the circumstances of the claim with the claimant. However, if fraud is suspected then Certifying Officers must contact the Local Counter Fraud Specialist for advice and not confront the employee directly. Local Counter Fraud Specialist can be contacted on Certifying Officers must check that sufficient detail and explanation is included on the claim regarding time spent or journeys undertaken by claimants. Explanations must be provided in circumstances where the employee has travelled further than the mileage given on the system and has over-written this Certifying Officers should check for reasonableness where an employee s duties require them to book external meeting room facilities or provide refreshments and/or light snacks to public attending such meetings prior any expenditure. No claims should be approved where claimants have personally purchased refreshments and/or light snacks which do not meet the criteria of subsistence allowances Where claimants submit claims for passengers, Certifying Officer must check that passenger names are included on the claim Certifying Officers should encourage staff to submit claims promptly after expenditure to assist with budget forecasting. Claims older than three months should only be authorised where exceptional circumstances exist Certifying Officers should ensure all transport and subsistence details are provided on the claim. Page 10 of 19

11 15.8. Only authorised signatories are permitted to authorise business travel and associated claims for staff The Online Expenses system asks claimants whether they have receipts for specific expense items. Claimants are instructed to provide these to the Certifying Officer by scanning them and attaching them to the claim. Certifying Officers must satisfy themselves that the receipts support the claim before authorising it. If a scanner is not available the claimant must provide the Certifying Officer with either the original of the receipt or a legible photocopy. Originals or photocopies must have the claimant s name, the claim month and year and claim reference allocated by the online expense system on them or affixed to them. Certifying Officers will need to set up a filing system for these for audit purposes and retain all receipts for a minimum of 5 years. 16. Interview Expenses All interview expenses must be agreed by the hiring manager before the interview date Candidates travel costs by car will be reimbursed at CCG mileage rate and any rail travel should be standard class and reimbursed at standard class rate Overnight stays before an interview will only be allowed in exceptional circumstances and will be reimbursed at the actual, receipted cost of bed and breakfast up to For candidates who withdraw their application or who refuse an offer of employment for reasons which seem inappropriate to the recruiting manager, expenses will not normally be reimbursed unless the manager is satisfied that the candidate would suffer real hardship as a result. 17. Monitoring Compliance and Effectiveness Certifying Officers are responsible for checking and monitoring travel and expense claims to ensure they comply with this policy Monitoring should include ensuring that the criteria for regular car allowances are being met by claimants authorised to receive payments at this level From time to time, the Local Counter Fraud Specialist and/or Internal Audit may undertake a review of travel and expense claims to ensure fraud is not affecting the CCG and that the systems in place are robust. Should any employee be found to be intentionally claiming incorrect mileage rates or claiming for any travel or expense to which they are not entitled, they may be liable to criminal investigation and/or disciplinary action and any overpayments recovered in full. 18. Interpretation In case of doubt, the definitive interpretation of the meaning of any of the content of this policy shall rest with the HR department. Page 11 of 19

12 19. References None. 20. Related Polices and Documents Alcohol & Substance Abuse Policy Anti-Fraud & Bribery Policy Blackberry & Mobile Phone Policy Disciplinary Policy Page 12 of 19

13 Appendix 1 GUIDANCE NOTES FOR STAFF AND MANAGERS ON EXCESS TRAVEL PAYMENTS 1. Introduction 1.1 This guidance document provides details for managers and staff on the payment of excess mileage from home to work where employees have been required to change their work base by the CCG. This guidance outlines when an employee is eligible to claim this excess mileage, the procedure for making a claim and also covers the process to follow when an employee (in receipt of excess travel payments) travels to other locations as part of their daily work. 2. Excess Travel as defined in paragraph of the Agenda for Change NHS Terms and Conditions Handbook 2.1 Change of Base of Work Resulting From Amalgamation of NHS Employers or From Acceptance of Another Post in Consequence of Redundancy. 2.2 Employees who are required to change their base of work as a result of a merger of NHS employers or their acceptance of another post as an alternative to redundancy may be reimbursed their extra daily travelling expenses for a period of 4 years from the date of transfer. The excess shall be calculated on the basis of the bus fares or standard rail travel or if the employee travels by private motor vehicle on the basis on the public mileage rate. 2.3 Excess travel mileage rates information is available on the CCG s intranet. 3. What is claimed? 3.1 The difference in mileage between the journeys from home to the old base and home to the new base is the excess mileage. For example: Home to old work base 15 miles Home to new work base 20 miles Excess mileage = 5 miles (single journey) This employee can claim 10 miles per day at excess mileage rate 4. For How Long? 4.1 An employee to whom excess travel applies is entitled to claim for four years from the date of transfer to the new base. As set out in the correspondence from HR. 5. Move of home address 5.1 Employees must notify their line manager of any change to their home address and excess mileage will be recalculated accordingly. If an employee who is claiming excess mileage moves their home address during the four year claim period, they are not entitled to any additional excess mileage as a result of this move of home address. If the move of home results in a lesser excess mileage, Page 13 of 19

14 the amount of excess mileage to be claimed will be recalculated accordingly and the lesser excess mileage paid. 6. Staff travelling to other locations as part of their role 6.1 There may be some occasions where it is more practical for the individual to travel from home rather than their work base as this will be the shorter distance. 6.2 The maximum travel claim that can be made is either calculated from the work base, plus excess miles (return) or actual mileage travelled, whichever is the shortest. 6.3 It should be noted here that the official mileage is calculated from the new work location rather than the old work location. 7. Temporary Transfer 7.1 Paragraph of the Agenda for Change NHS Terms and Conditions Handbook states: Employees who are required by their employer to carry out temporary duties at a place other than their permanent place of employment and who travel daily to their temporary headquarters whilst continuing to live near their permanent headquarters, may be reimbursed their excess travelling expenses in accordance with locally determined provisions for expenses incurred in connection with removals. 8. Additional Costs Please note that there is no reimbursement for additional costs e.g. car parking at new base. 9. Principles of Excess Travel In defining the method for claiming excess travel the following principles should apply: Excess travel is the difference between home to old and new work base. Official mileage must be calculated in relation to new base, not the old base. Travel expenses is not an income, it is a reimbursement of expenses. 10. Managers are advised to monitor the period of excess travel claims and ensure that copies of the appropriate forms to payroll are on personal files. Any queries relating to excess mileage entitlements or the procedure for claiming mileage should be directed to your Human Resources Department. Page 14 of 19

15 Appendix 2 How to calculate Mileage Employees will be reimbursed for miles travelled in the performance of their duties which are in excess of the home to agreed work base return journey. Normally, the miles eligible for reimbursement are those travelled from the agreed work base and back. However, when the journey being reimbursed starts at a location other than the agreed work base, for example home, the mileage eligible for reimbursement will be as set out in the example in Table below and following diagrams. Eligible mileage illustrative example In this example the distance from the employee s home to the agreed base is 15 miles Journey (outward) Distance Eligible miles Home to base 15 miles None Eligible mileage starts after 15 miles have been Home to first call Less than 15 miles travelled Home to first call More than 15 miles Eligible mileage starts from home, less 15 miles Journey (return) Last call to base Eligible mileage ends at base Last call to home Less than 15 miles Eligible mileage ends 15 miles from home Last call to home More than 15 miles Eligible mileage ends 15 miles from home Page 15 of 19

16 How to calculate eligible mileage (examples) 15 miles 15 miles in total travelled 0 miles to be claimed home base 25 miles 25 miles in total travelled 25 miles to be claimed base Destination 12 miles 12 miles in total travelled 12 miles to be claimed Destination Page 16 of 19 base

17 How to calculate eligible mileage when you finish at home Journey (return) Destination 10 miles home 10 miles in total travelled take away home to base 0 miles to be claimed Destination to home more than home to base Destination 20 miles home 20 miles in total travelled take away home to base 5 miles to be claimed Page 17 of 19

18 Appendix 3 Equality Impact Assessment Stage 1 Screening 1. Policy EIA Completion Details Title: Travel and Expenses Policy Proposed Existing Date of Completion: June 2013 Review Date: June 2015 Names & Titles of staff involved in completing the EIA: Jenny Ambrose, Senior HR Advisor 2. Details of the Policy. Who is likely to be affected by this policy? Staff Patients Public 3. Impact on Groups with Protected Characteristics Age Being married or in a civil partnership Disability, inc. learning difficulties, physical disability, sensory impairment etc. Having just had a baby or being pregnant Race, ethnicity, nationality, language etc. Religion or belief Sex (inc. being a transsexual person) Sexual Orientation Other: Probable impact on group? Positive Adverse None High, Medium or Low Please explain your answers Arrangements for flexible working should support staff with a disability to gain and retain employment No impact on any of the groups above. Please explain and provide evidence The policy provides information on a range of employee benefits open and accessible to all staff, regardless of any individual or protected characteristics. 4. Which equality legislative Act applies to the policy? Human Rights Act 1998 Equality Act 2010 Health & Safety Regulations Mental Health Act 1983 Mental Capacity Act How could the identified adverse effects be minimised or eradicated? 6. How is the effect of the policy on different Impact Groups going to be monitored? HR/Payroll databases can monitor changes to working patterns, career Breaks, Leave etc Page 18 of 19

19 Appendix 4 Privacy Impact Assessment Stage 1 Screening 1. Policy PIA Completion Details Title: Travel and Expenses Policy Proposed Existing Date of Completion: June 2013 Names & Titles of staff involved in completing the PIA: Jenny Ambrose, Senior HR Advisor Review Date: June Details of the Policy. Who is likely to be affected by this policy? Staff Patients Public Yes No Please explain your answers Technology Does the policy apply new or additional information technologies that have the potential for privacy intrusion? (Example: use of smartcards) Identity By adhering to the policy content does it involve the use or re-use of existing identifiers, intrusive identification or authentication? (Example: digital signatures, presentation of identity documents, biometrics etc.) By adhering to the policy content is there a risk of denying anonymity and deidentification or converting previously anonymous or de-identified data into identifiable formats? Multiple Organisations Does the policy affect multiple organisations? (Example: joint working initiatives with other government departments or private sector organisations) Data By adhering to the policy is there likelihood that the data handling processes are changed? (Example: this would include a more intensive processing of data than that which was originally expected) If Yes to any of the above have the risks been assessed, can they be evidenced, has the policy content and its implications been understood and approved by the department? Page 19 of 19

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