RMO Claim Form

To be completed by RMOs who are currently permanent employees of the DHB in which the duties were undertaken.
RMOs who are not currently permanent employees must complete the Locum Duty Claim Form

Please complete immediately following your duty/duties and submit completed form to your RMO Support Unit/Support Person
*Mandatory fields must be completed
General Information Specific Claim Information
*Current Run: ________________________________ *DHB: Auckland / Counties / Waitemata Dept/Service where duty was worked: _____________________________
(circle one)
* Last Name: ___________________________________________________________________ RC Code (if known):

First Name: _________________________________ * Employee No: _____________________ Person covered for : ______________________________________________

Reason for cover : _______________________________________________

*Registrar / House Officer (circle one) Other: ___________________________ (please specify)
RMO to Complete RMO Support/Payroll to Complete
*RMO Claim Type Date Public Start Finish Hours #Rate $ RMO RC Code Override
(Note: One form for each Service/Department) Holiday Time Time Worked RMO Support Payroll Codes RC Code to be Account
(tick box) Support to to Calculate charged Code
Complete (7 digits) (4 digits)
Additional Duties - House ADHS/ADRG/ADSD/ADSN 2
Officer/SHO/Registrar ADHS/ADRG/ADSD/ADSN 2
ADHS/ADRG/ADSD/ADSN 2
ADHS/ADRG/ADSD/ADSN 2
ADHS/ADRG/ADSD/ADSN 2
Cross Cover - House Officer/Registrar CCHO/CCRG 2
CCHO/CCRG 2
CCHO/CCRG 2
No 8 Hour Break NO8 2
Emergency Back Up Roster EBUP 2
Excess Hours (Clause 13.3 of the contract e.g.
EX72/EX14 2
exceeding 72 hours in 7 days)
Parental Leave Lump Sum MTLS(
Date commenced Parental Leave:_____________________ Date returned from Parental Leave:______________________ C)
MTLS 2
PARL(
Length of Parental Leave:_____________________________ (Note: Payroll to calculate payment) W)
DHB I worked at when I commenced parental leave: Public Holiday Hours to be Credited: (for Additional
Duties on a Public Holiday)
#Note: For Public Holidays, T1/2 rate must be recorded
Comments: Approved/Declined by Employer
I certify that the above are valid RMO expenses and were incurred in the course of my employment with the District Health
Board and the amount claimed is in accordance with my employment agreement. Name: __________________________________________________________

* RMO Signature:____________________________________________ Date: _______________________ Signature: _________________________________ Date:_________________

Section: 12 & 16 RMO Claim Form Issued: July 2005

Auckland Regional RMO Support Manual Page 1 of 1 Updated: April 2015 Applicable DHB RDA MECA 21 January 2015 expiry date 29 February 2016