EMAS Overtime Payments & Annual Leave Questionnaire
If you wish us to consider whether you have a potential claim for a failure by your employer to include overtime that you have worked in calculating your holiday pay, please complete this form in as much detail as possible.
Email address *
Membership Number (leave blank if unknowns)
Your answer
Title
Forename *
Your answer
Surname *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Full Address *
Your answer
Telephone *
Your answer
Payroll Number
Your answer
Job Title *
Contracted Hours *
Your answer
Hourly Pay *
Your answer
Pay Band *
Your answer
Do you work under the NHS Agenda for Change contract? *
Do you regularly work overtime? (inc End of Shift / Overrun) *
What type of overtime do you work?
Estimated Number of hours per week worked overtime?
Your answer
If you work Mandatory overtime, are you paid this when on Annual Leave?
If you work Voluntary overtime, are you paid this when on Annual Leave?
If you work End of Shift overtime, are you paid this when on Annual Leave?
When did you last take Annual Leave where you think you were underpaid because of overtime that you worked?
Your answer
AUTHORITY: It is important that you understand that your Union are investigating a number of possible similar claims. To facilitate the conduct, co-ordination and settlement of those claims, it is important that you give the following authorities and by signing this questionnaire, you authorise the investigation of your own individual case and the following: (1) I authorise the Union’s solicitors to take instructions on the conduct of my potential claim, including the issuing of Tribunal proceedings. (2) I agree and understand that I must continue to pay my Trade Union subscriptions throughout the period of any claim pursued on my behalf, even if my present employment ends. (3) I understand that I am free at any time to revoke this authority but that if I do so the Union and/or solicitors will be unable to act for me. *
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