Please download and print this form.
You need to fill this form in and bring it with you when you get your COVID-19 booster.
On the paper copy of the form:
- Add your NHS number – if you don’t know it, you can find your NHS number online or on your NHS App.
- Add your payroll number – your payroll number can be found by logging in to ESR and is on your payslip as ‘assignment number’. If you are not paid by the trust (for example junior doctors), you can leave the payroll number blank but you must add your NHS number.
- Add your telephone number
- Add GP details
- Add ethnicity
- Complete the pre-vaccination self-assessment section, circling yes and no
You will also need to know the date you had your last COVID-19 dose.
Remember to bring your Staff ID badge.
If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email [email protected] to tell us what format you require. It will help us if you let us know what type of assistive technology you use.