Please read these notes carefully before completing the form. This online form is used to reimburse schools from the Cover for Absence Mutual Fund.

Please note: This form should not be used where teachers are on Half or Stop Pay

Please note that this online form replaces the CTB1, CTB2-SP, CTB1-SP and CTB1A-SP forms.

Primary Schools - A form is only required when a teacher has been absent for a continuous period of 10, 5, 15 or 10, 8, 14 working days in the case of 'small' schools dependent upon the option 'purchased' from the Mutual Fund (where a teacher is employed for less than full time the actual days will be proportionately greater , e.g., half time 0.5 pay factor rate, the waiting period will be 20 days under Option 1).

Secondary Schools - A form is only required when a teacher has been absent for a continuous period of 20, 15 or 25 working days or more dependent upon the option 'purchased' from the Mutual Fund (where a teacher is employed for less than full time the actual days will be proportionately greater , e.g., half time 0.5 pay factor rate, the waiting period will be 40 days under Option 1).

Special Schools - A form is only required when a teacher has been absent for a continuous period of 10, 8 or 14 working days or more dependent upon the option 'purchased' from the Mutual Fund. The first 10, 8 or 14 days of each period of continuous sickness do not count for reimbursement.

Section 1 - School Details

1.) School Type:

Select the type of school (Primary, Secondary or Special) from the drop-down list.

2.) Teacher or non-teacher claim:

Select teacher or one of the non-teacher options from the drop-down list.

3.) Type of claim:

Select the type of claim, either 'Continuous' or 'Phased Return'.

3a.) Claim Percentage:
If the employee has completed work remotely and has not been signed off by a GP, please confirm the percentage of full claim. E.g. If a teacher completed equivalent to 20% of their contracted hours remotely during a month, then a claim can be submitted for the 80% of hours that weren't worked during the month. (Please be aware that claims are still subject to regular Mutual Fund terms, found on the Mutual Fund website: https://www.devon.gov.uk/supportforschools/finance/mutual-fund) If this is a regular, 100% Mutual Fund claim, please type 100% into the answer box.

Enter the school name.

5.) School DCSF No. (4 digits only):

Enter the DCSF number excluding the 878.

6.) Month of claim:

Select the month the claim refers to.

7.) Financial year of claim:

Select the year the claim refers to.

 Section 2 - Staff Details

8.) Title:

Select the title of the individual from the drop-down list.

9.) Surname:

Enter the surname of the individual.

10.) First Name:

Enter the first name of the individual.

11a.) Nature of absence:

Select the nature of the absence from the drop-down list. If the nature of the absence is not listed, please select 'Other' and answer question 12b.

11b.) If other was selected, please state the nature of the absence:

If other was selected in question 12a then please enter the reason of the absence.

12.) Pay Factor Rate:

Select the Pay Factor Rate from the drop-down list.

Section 3 - Continuous Claim Details (only required if the claim is 'Continuous' as selected in question 3)

13.) First day of sickness:

Enter the first day of sickness (this may not be a school day). Please enter the date as dd/mm/yyyy.

Continuous Claims: The claim period starts from April 1st of each year. Days may only be carried forward from the previous financial year when a teacher has been sick for a minimum period of 10, 5 or 15 working days in Primary or Special Schools and 20, 15 or 25 working days in Secondary Schools immediately prior to the 1st April.

14.) Days c/fwd from previous month(s)

Enter the number of school days qualifying for re-imbursement carried forward from the previous claim.

15.) First actual sickness date this month - From:

Enter the first actual day of sickness this month. Please enter the date as dd/mm/yyyy

16.) Last actual sickness date this month - To:

Enter the last actual day of sickness this month. Please enter the date as dd/mm/yyyy

17.) Pupil days claimed this month

Enter days claimed. Do not include non-pupil days, Saturdays, Sundays or holidays. Whilst calendar dates must be shown, only school dates may be claimed.

18a.) If applicable, please enter the date the school term began for pupils

If the claim is in the same month as when the school term began, please enter the date the school term began for pupils. Please enter the date as dd/mm/yyyy.

18b.) If applicable, please enter the date the school term ends for pupils

If the claim is in the same month as when the school term ends, please enter the date the school term ends for pupils. Please enter the date as dd/mm/yyyy.

19a.) If applicable, please specify Half Term days within this period

If the claim is in the same month as Half Term, please enter the date within this period.

19b.) If applicable, please specify non pupil days within this period

If the claim is on the same month as non-pupil days occur, please enter the days within this period.

Section 4 - Phased Return To Work Details (only required if the claim is a 'Phased Return' as selected in question 3)

20) Has the school contacted Wellbeing@Work and received the referral report from Wellbeing@Work?

Phased Return claims will be paid the daily re-imbursement rate for teachers and support staff for all days that a member of staff is absent during the phased return. However, an independent report from Wellbeing@Work confirming that a phased return is necessary will be required before a claim can be made.

21) Length of phased return (in weeks).

Select the length of the phased return. This will be mentioned within the Wellbeing@Work report.

22) Start date of the phased return (dd/mm/yyyy)

Enter the start date of the phased return. Please enter the date as dd/mm/yyyy.

23) End date of the phased return (dd/mm/yyyy)

Enter the end date of the phased return. Please enter the date as dd/mm/yyyy.

24) Pupil days claimed during phased return to work (i.e. total number of days not at work during the phased return)

Enter days claimed. Do not include non-pupil days, Saturdays, Sundays or holidays. Whilst calendar dates must be shown, only school dates may be claimed.

25a) If applicable, please enter the date the school term began for pupils (dd/mm/yyyy)

If the claim is in the same month as when the school term began, please enter the date the school term began for pupils. Please enter the date as dd/mm/yyyy.

25b) If applicable, please enter the date the school term ends for pupils (dd/mm/yyyy)

If the claim is in the same month as when the school term ends, please enter the date the school term ends for pupils. Please enter the date as dd/mm/yyyy.

26a) If applicable, please specify Half Term days within this period

If the claim is in the same month as Half Term, please enter the date within this period.

26b) If applicable, please specify non pupil days within this period

If the claim is on the same month as non-pupil days occur, please enter the  days within this period.

Section 5 - Authorisation

27a.) I certify that the above is an accurate record of teacher/non-teacher absence for the period shown. I claim reimbursement in accordance with the SMF scheme. I understand that if an overclaim is made this may be subsequently adjusted:

By ticking this check box, the individual completing the form is certifying that the claim is an accurate record of the absence and that should the claim form be filled out incorrectly then the claim may be rejected or adjusted.

27b.) Certified by (please provide your name):

Enter the name of the individual who has filled the Mutual Fund claim form.

27c.) Date certified:

Enter the date the claim form was completed. Please enter the date as dd/mm/yyyy.