Practice Placement Epenses (Travel and Accommodation) Claim Form Universities should send completed forms to the address below. Please do not include any staples or sellotape and ensure the form has been signed and stamped to authorise it. NHS Student Bursaries, Ridgway House, rthgate Close, Middlebrook, Horwich, Bolton, BL6 6PQ NHS Student Bursaries contact details: www.nhsbsa.nhs.uk/students Helpline: 0300 330 1345 (opening hours: Mon - Fri 8am - 6pm and Sat 9am - 3pm) Please read the guidance notes BEFORE you complete this form. Completed forms should be returned to your University who will certify them and send them to NHS Student Bursaries. You MUST remember to include a copy of your student coversheet with each form as your claim cannot be processed without this. 1. Personal Details - you must complete this section in full. Student reference number SBA When did you first start your course? Between 01/09/2007 and 31/08/2012? On or after 01/09/2012? Surname Other names Title Mr Mrs Miss Ms Other Date of birth / / Term-time address Contact/mobile number Correspondence address 2. College / Course Details - you must complete this section in full. Name of University/College Name of Course Type of Course Full-time Part-time 1 of 8
3. Details of normal daily travel to study - you must complete this section in full. Full address of your place of study. This should be the University address of the place you attend on a regular basis. How do you travel to your place of study? (If you walk, please specify in the bo) If you use public transport, please indicate the cost of your DAILY return journey. If you drive or cycle to University, please indicate the DAILY return mileage. Bo A PLEASE NOTE: Car Share/Lift to University - you must still show how far the DAILY return journey is from your termtime address to your place of study. We need to assume that you bear the entire cost of travelling to University each day. This is the figure that will be used to determine whether or not your placement travel costs are in ecess of your normal travel to University. Failure to complete any of the above will result in your claim form not being certified by your University. 4. Details of travel to and from your Practice Placement - you must complete this section in full. FULL address of your practice placement site How do you travel to your practice placement site? If you use public transport, please indicate the cost of your DAILY return journey. If you drive or cycle to placement, please indicate the DAILY return mileage. Bo B Failure to complete any of the above will result in your claim form not being certified by your University. If you started your course on or after 1 September 2012, please deduct Bo A from Bo B above and insert the amount in the bo. 2 of 8
5. Details of Accommodation Epenses - you must complete this section in full. Are you living at a different address whilst out on practice placement? go to Section 6 Do you live with your parents during term-time? ALL STUDENTS: We DO NOT require proof of maintaining your term-time address if you reside with your parents. Parental address You MUST complete this section in full Address where you stayed whilst on practice placement You MUST complete this section in full What was the period of your practice placement? For Office use only From / / to / / What was the period of occupancy at your practice placement? From / / to / / Are you claiming for the full period of your placement on this claim? If NO please give the dates you wish to claim for i.e. if 3 months placement but only claiming for 1 month on this claim only provide the 1 month time period dates. Dates claiming for: From / / to / / What is the cost of maintaining your practice placement address? YOU MUST SEND PROOF To be completed by students who started their course before 1 September 2012. PLEASE NOTE: If you normally reside with your parents during term-time the cost of your term-time address is normally set at 20.00 per day (30.00 per day if you study at a London based University), and payment, if appropriate, will be made at this rate. Your bursary will have already been assessed at the parental home rate. What is the cost of maintaining your term-time address whilst on practice placement? YOU MUST SEND PROOF 3 of 8
6. Details of claim - you must complete this section in FULL (please photocopy this section if necessary) Please show FULL details of each journey for which you are claiming and attach receipts as necessary. Date Journeys Private Mileage Public Transport Other Allowable Costs From To Miles Community mileage - Do not include in previous miles column Passenger miles Means of transport (bus, train) Cost of transport Tunnel and road tolls/car parking 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TOTALS 4 of 8
7. Summary of claim - you must complete either Section 7a or 7b in FULL 7a. ONLY to be completed by students who started their course before 1 September 2012. Please use this section to summarise the details of your claim using Sections 5 and 6. Summary of Private Mileage Mode of Transport Total number of miles, including community mileage Mileage rate Total amount Bicycle 6.2 pence Vehicles up to 125cc (mopeds and small motorcycles) 16.2 pence Vehicles over 125cc (cars and large motorcycles) 23 pence Full name of any passenger(s) claimed for: Each passenger must be an NHS funded student. Full name of passenger Passenger s SBA number Date of birth. of miles Mileage rate Total amount Total cost of private mileage Total cost of public transport Total allowable costs, if any (e.g. community mileage, car parking, tunnel charges, tolls roads etc.) Total transport costs Total accommodation costs 5 of 8
7b. ONLY to be completed by students who started their course on or after 1 September 2012. You may claim the difference between the cost of your daily travel to placement and the cost of your daily travel to your normal place of study. Please use this section to summarise the details of your claim using Sections 5 and 6. Summary of Private Mileage Mode of Transport Total number of miles, including community mileage Mileage rate Total amount Bicycle 6.2 pence Vehicles up to 125cc (mopeds and small motorcycles) 16.2 pence Vehicles over 125cc (cars and large motorcycles) 23 pence Total Bo C Full name of any passenger(s) claimed for: Each passenger must be an NHS funded student. Full name of passenger Passenger s SBA number Date of birth. of miles Mileage rate Total amount Total cost of private mileage (including community mileage) Bo C Total cost of public transport Bo D Total allowable costs, if any (e.g. car parking, tunnel and road tolls) Bo E Enter the total cost of your placement travel this claim. Bo C + Bo D + Bo E Bo F Enter the total normal cost of your return daily travel to your University / normal place of study during the period of this claim. Bo G To calculate the maimum travel costs you are entitled to this claim, deduct your daily travel to University from the total cost of your placement travel. Bo F minus Bo G Total accommodation costs Bo H Bo I 6 of 8
8. Student s Declaration - You must complete this section in FULL I confirm that I have read and understood the Guidance tes and my claim for reimbursement of epenses for travel and accommodation reasonably incurred as a direct result of attending my clinical placement. I confirm that where I make a claim for epenses as a result of using my own motor vehicle, this use has been authorised by my University, and that my motor insurance policy covers all relevant claims and costs and that no liability is placed on the University or on any NHS body. I declare that the information given on this form and in any supporting documents provided is complete and accurate. I understand and accept that if I provide false or misleading information, I may be liable to prosecution and/or civil proceedings and debt collection. I understand that the administration of NHS Student Bursaries and responsibility for counter fraud and security management in the NHS are both responsibilities of the NHS Business Services Authority. I understand that NHS Student Bursaries may share the information on this form with the NHS Protect for the purposes of the prevention, detection, investigation and prosecution of fraud or any other unlawful activity affecting the NHS. Signature Date / / It is imperative that you keep photocopies of all forms and receipts before passing these to your University for authentication. Please see net page for University/College Authorisation. 7 of 8
9. University/College Authorisation - Your University must complete this section in full Is this placement that the student is claiming for, an elective or non-elective placement? Elective n-elective An elective placement is where the student has chosen to attend and has chosen the location. A non-elective placement is classed as an integral part of the student s course and qualification would be conditional upon its completion. Checklist Has the student completed ALL the relevant sections? Return form to student Are ALL accommodation receipts attached, where appropriate? Return form to student Have you authorised the means of transport used? (If the student has used tais, please enclose a letter) Return form to student If the student is using their own vehicle, have you confirmed that they have adequate motor vehicle insurance cover for travelling to and from their placement? t applicable Return form to student Declaration I declare that I am an authorised officer of the University/College named in Part 2 of this form. I confirm that the person named at Part 1 of this form is a student at the Higher Education Institution named in Part 2 of this form and that: as part of their course the institution requires them to spend the period(s) of time specified in this form away from their normal place of study for the purpose of clinical training or overseas study; the claim for epenses detailed in this form has been reasonably and necessarily incurred in accordance with the provisions of the NHS Bursary Scheme. Where the student named at Part 1 of this form has made a claim for use of their own motor vehicle, I confirm that this has been authorised by the University/College named in Part 2, who are satisfied that the student has adequate motor vehicle insurance for the journeys undertaken whilst travelling to and from their placement. I understand and accept that if I provide false or misleading information, I may be liable to prosecution and/or civil proceedings and debt recovery. I understand that the administration of NHS Student Bursaries and responsibility for counter fraud and security management in the NHS are both responsibilities of the NHS Business Services Authority. I understand that NHS Student Bursaries may share the information on this form with the NHS Protect for the purposes of the prevention, detection, investigation and prosecution of fraud or any other unlawful activity affecting the NHS. Signature Date / / University/College stamp Print Name Position held 8 of 8