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About Me

Please complete each section below.

Employment Details

Please indicate which staff group you fall under

Northumbria Healthcare Staff

Student

LET Doctor

NHCFT Volunteer

Other

You must select one before submitting.

Your Details

NHS No

Do not know you NHS number?You can find it here Search

I live outside of England, Wales or the Isle of Man.

Employee Number

Forename

Surname

Date of Birth / /

Your Contact Details

Email

Confirm Email

Contact No

Consent Questions

Please read the questions carefully and confirm that all answers given are correct.

If you have any questions then please contact us via one of the below options:

Email: vaccinationteam@northumbria-healthcare.nhs.uk

Phone: 0191 349 9643

Does the individual have a history of anaphylaxis or significant allergic reactions to any vaccines or its ingredients?

Yes

No

Has the individual experienced any serious adverse reaction after previous COVID-19 vaccine doses?

Yes

No

Are you pregnant?

Yes

No

Not Stated

You must select one before submitting.

Consent Confirmation

I agree to the proposed vaccination, which will be explained to me by the health professional.

Yes

No

You must agree before submitting.

I consent to the information that I have had the vaccine being shared with my Manager for health protection purposes.

Yes

No

You must agree before submitting.

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