Fillable NHS Student Bursaries - Practice Placement Expenses (travel (UK National Health Service)

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NHS Student Bursaries - Practice Placement Expenses (travel (UK National Health Service)

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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
NHS Student Bursaries - Practice Placement Expenses
(travel and accommodation) claim form
This form is for NHS Bursary students only.
A step by step guide to completing your PPE claim form is available if you need any guidance in completing
this form. Completed forms should be returned to your university along with your student cover sheet.
All PPE claims must be received within nine months of the last day of the practice placement for which you
are claiming.
1. Personal Details - you must complete this section in full.
Student reference number
Surname
Forename(s)
Date of birth
Term time address
Contact telephone number
Email address
Postcode
SBA
You can obtain this number by
logging on to your BOSS account
/ /
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
2. Your course and study base
Name of university
Name of course
Course year
Full address of your normal
place of study (including
post code)
Postcode
3. Travel to your normal place of study
How do you normally travel to the above location? If your method of travel varies, you should select the option
which applies to you the majority of the time.
Tick one box only.
A. Walk
B. Receive a lift from someone else
C. Public transport
D. Drive own vehicle
E. Cycle
If you ticked C (public transport)
State the total daily return cost
£
or
If you use a travel pass or season ticket, provide the total cost of this and state whether this is weekly / monthly /
annually
If you ticked D or E
What is your normal return mileage per day?
If you usually incur parking, tunnel or toll road
costs, give the total daily cost of these
£
Information
If you are able to claim back any reimbursement for the cost of the above travel directly from your
university, you must still provide details of the full cost of your actual travel (before
reimbursement) as above.
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
4. Details of your practice placement
FULL address of your
practice placement site
If you were based at more
than one site provide an
address for each one
Postcode
/ /
/ /
Start date: End date:
Postcode
If you used public transport to placement show the cost of your daily return
journey.
If you drove or cycled to placement show the daily return mileage.
Car hire
Cost to you of hiring the car (you must provide evidence)
Overseas placement - other costs
If your placement took place outside the UK (including the Channel Islands or Isle of Man) you may be entitled to
reimbursement for essential vaccinations/medication, medical insurance and any required visas.
If applicable, enter details below and provide evidence of the costs with your claim form.
Essential vaccinations/medication/tests
Medical insurance
Visa(s)
You should detail any travel and accommodation costs at sections 5 and 6.
£
£
£
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
5. Details of claim
Please provide details of each daily return journey to placement. If you are claiming for more than 20
journeys for this placement period you should print off and complete additional copies of this page of
the claim form, as required.
Date Journeys
Total daily mileage
including mileage
undertaken if you
used a hire car
Public transport Other
Postcode
from
Postcode
to
Return daily
mileage to
placement
site
Community
mileage
Means of
transport
(bus, train)
Cost of
transport
Tunnels, toll
roads and
car parking
Passenger
miles
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TOTALS
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
6. Placement accommodation costs
If you had to take up temporary (secondary) accommodation away from your normal term time address in
order to attend your practice placement, and you incurred dual costs as a result, complete this section.
You cannot claim reimbursement if you stayed with your parent(s) in their home in order to attend your
placement. If this is the case do not complete this page and go to Section 7.
Full address of your
placement accommodation
Postcode
Period you are claiming for:
From to
/ /
/ /
Total cost (to you) of your placement accommodation for the above period
(You must include official evidence of this with your claim form)
£
Do you live in the parental home during term time?
Yes
Go to Section 7
No
If no, state the approximate cost of your normal term time accommodation
during the above dates.
£
You do not need to provide evidence of your normal term time address costs, but in some cases, we may contact you
for further information.
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
7. Summary of claim
7a. Transport and passenger details.
Complete this section in full.
Summary of private mileage
Mode of transport
Total number of
miles, including
community mileage
Mileage rate Total amount
Bicycle
x
20 pence
=
Motor vehicle
x 28 pence =
Passengers
If you took other NHS student/s to/from placement, enter their details below. Each passenger must be an NHS
bursary funded student.
If you are not claiming for any passengers, go to Section 7b.
Full name of passenger
Passenger’s SBA
number
Date of
birth
No. of
miles
Mileage
rate
Total amount
1
x 5 pence
2
x 5 pence
3
x 5 pence
4
x 5 pence
Passenger mileage - dates of travel
Please state on which dates you took the above named passengers to placement. If you took them every day of
the placement, enter ‘all’ in the ‘Date/s passenger/s taken to placement’ column below.
Passenger Date/s passenger/s taken to placement
First passenger (as above)
Second passenger (as above, if applicable)
Third passenger (as above, if applicable)
Fourth passenger (as above, if applicable)
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
7b. Summary of costs
Reimbursement of travel costs is limited to the difference between the cost of your daily travel to
placement and the cost of your daily travel to your normal study base.
Total mileage costs
Total public transport costs
Other travel costs, (car parking, car hire, tunnel charges, road tolls)
£
£
£
+
+
=
Total cost of all your placement travel this claim
£
Total cost of your normal travel to university
This is the total return cost of your daily travel to university (section 3) multiplied by the total number of
days on placement (section 5). Refer to the mileage rates above to calculate the cost.
£
minus
=
To work out the total amount of travel costs you can claim, deduct your total
daily travel to university from the total cost of all your placement travel.
£
Overseas placement - total cost of vaccinations, visas and/or medical insurance
£
Placement accommodation costs
Enter the amount for your placement accommodation costs if applicable.
£
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
8. Student’s declaration - You must read, sign and date this section in all cases
Please review all information you have provided before completing this declaration. Read this declaration carefully
before accepting it. If you choose not to accept it, your funding application will not be processed.
I declare that:
a) I am undertaking a pre-registration healthcare programme at a university in England or I am undertaking a
pre-registration Medical or Dental course at a university in the UK that is eligible for Practice Placement
Expenses.
b) I have read and understood the relevant booklet and/or any other relevant information regarding the
conditions for claiming Practice Placement Expenses.
c) I confirm that I have enrolled and commenced on my programme of study and am thus in active training.
d) I confirm that the expenses claimed were essentially incurred as a result of my attending practice placements
and that my normal daily travel to university costs have been deducted.
e) I confirm that I have used the cheapest available transport to access the practice placement/s.
f) I confirm that, if I have claimed for a private motor vehicle, I have appropriate insurance in place.
g) I confirm that I am not studying as an assisted student i.e. I am not in receipt of any sponsorship from an
employer or any other agency.
h) Student Services is committed to administering entitlement accurately wherever possible. I agree to pay back
Student Services within 30 days of receiving notification any excess payment, fees and any other charges, in
the event of the following circumstances:
• Changing my study pattern from full-time to part-time
• Withdrawing, abandoning, suspending, deferring or interrupting the course permanently or temporarily for
any reason, regardless of whether I intend to return
• Taking a year out from study
• Being overpaid because I have failed to notify NHSBSA Student Services of a change in my circumstances.
• Where Student Services at its absolute discretion determines I have been given financial support to which I
am not entitled
• Gaining support from sources other than Student Loans Company that might affect my entitlement
Should I fail to make full repayment of any amount due or agree an acceptable repayment plan with NHSBSA,
I understand that the debt may be passed to a debt collection agency. I also understand that I may be charged
for any additional recovery costs and/or interest at the rate of 8% on the referred debt which may be added to
the balance.
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
i) I consent to the disclosure of information on this form on the following understanding:
Privacy Notice
Student Services privacy notice
The NHS Business Services Authority (NHSBSA) is responsible for this service.
Why we process your information
We will use the information you provide to:
• assess your application
• pay you
• detect and prevent fraud and mistakes
• help plan and make improvements to NHS services, and/or direct patient care
By law, we must process this information on behalf of the Department of Health and Social Care (DHSC).
Sharing your personal information
To prevent, detect and investigate fraud and errors, we may share your information with:
• Student Loans Company
• HM Revenue and Customs
• higher education institutions
• the Home Office
• organisations from which you receive benefits, bursaries, grants or support
• bodies performing functions on behalf of the above organisations
We may share information with the DHSC to investigate and prosecute fraud, or any other unlawful activity affecting
the NHS.
We may share information with the Cabinet Office in relation to the National Fraud Initiative.
Anonymised information may also be shared with the DHSC to monitor compliance with equality law.
Information that identifies you will not be transferred outside the
European Economic Area.
Keeping your personal information
We will delete your data no later than seven years after your course finishes.
Your rights
The information you provided will be managed as required by Data Protection law.
You have the right to:
• receive a copy of the information the NHSBSA hold about you
• request your information be changed if you believe it was not correct at the time you provided it
From 25 May 2018, you have the right to:
• request that your information be deleted if you believe we are keeping it for longer than necessary
Find out more about
your rights and how we process information.
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
I understand that the administration of Practice Placement Expenses and responsibility for counter fraud and security
management in the NHS are both responsibilities of the NHS Business Services Authority. I understand that NHSBSA
Student Services may share the information on this form with NHS Counter Fraud Authority for the purposes of the
prevention, detection, investigation and prosecution of fraud or any other unlawful activity affecting the NHS.
I understand and accept that if I fail to give sufficient notice of any change to my bank or building society
account details, or provide incorrect details, NHSBSA Student Services cannot take responsibility for
payments made to an incorrect account, delayed payments or non-payment of the funding.
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 NHS Counter Fraud Authority for the purposes of the
prevention, detection, investigation and prosecution of fraud or any other unlawful activity affecting the NHS.
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 NHSBSA Student Services with false or misleading information,
financial support may be refused or withdrawn and I may be liable to prosecution and/or civil proceedings.
Any future amendments to this application will require you to re-accept this declaration.
Signature
Date
/ /
You are advised to make a copy of your form and any receipts or invoices before passing your claim to your
university. Remember to include a copy of your BOSS student coversheet with this claim.
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Practice Placement Expenses (travel and accommodation) claim form (V9) 08/2020
9. University authorisation - university to complete this section
Checklist
Has the student completed ALL the relevant sections
Yes
No
Return form to student
and signed and dated the declaration?
No
Return form to student
Have you authorised the means of transport used?
Are ALL accommodation receipts attached, where appropriate?
Yes
No
Return form to student
Yes
(If the student has claimed for taxi journeys, please enclose a letter)
No
Return form to student
Has the student provided you with a student coversheet?
Yes
Has the student submitted this form to you within nine months
Return form to student -
No
Yes
of the final date of the placement period for which they are
no expenses can be paid
claiming?
Declaration
In countersigning this claim for Practice Placement Expenses, I confirm the following:
• The student named at Section 1 of this form is studying on a pre-registration healthcare programme that is, to the
best of my knowledge, eligible for Practice Placement Expenses.
• The practice placement/s for which the student is claiming the Practice Placement Expenses were essentially
incurred as part of the overall programme requirements.
• The expenses detailed in this claim form have been reasonably and necessarily incurred in accordance with the
provisions of the policy
• The student’s normal daily travel to university costs have been deducted, where applicable.
• I have checked the claim and, to the best of my knowledge, confirm that the expenses being claimed are correct.
• I have checked the receipts where applicable.
• The receipts will be retained in line with this institutions audit and governance requirements.
• I am a registered employee of the higher education institution that the student attends, and I have authority
agreed by the higher education institution to countersign Practice Placement Expenses claims.
• I understand and accept that if I provide false or misleading information, I may be liable to prosecution and/or civil
proceedings.
• I understand that the administration of Practice Placement Expenses and responsibility for counter fraud and
security management are both responsibilities of the NHS Business Services Authority.
• I understand that Student Services may share the information on this form with NHS Counter Fraud Authority for
the purposes of the prevention, detection, investigation and prosecution of fraud or any other unlawful activity
affecting the NHS.
Signature
Date
Email address
Print name
Position held
/ /
University official stamp
Universities should send completed forms to NHS Student Bursaries, Ridgway House, Northgate Close,
Middlebrook, Horwich, Bolton, BL6 6PQ.
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NHS Student Bursaries - Practice Placement Expenses (travel (UK National Health Service)

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