Request for details of immunisation history

Please use the form below to submit a request to the occupational health team for details of your immunisation history.

A charge of £10.00 will be made if a duplicate copy is required.

Details of immunisation history can only be requested if you are current staff or have left the Trust within the last six months.

Please use this format: dd-mm-yyyy

Please note: by giving a personal email address the information requested will not be sent encrypted.

Are you a new starter to the Trust?

Yes No

I hereby give permission for information relating to my immunisation record which is held with Surrey and Sussex Healthcare NHS Trust occupational health to be released to the email stated on this form.

I accept

Please type your full name to complete the e-signature.

Date

Please enter today's date. Please use this format: dd-mm-yyyy

Please bear in mind that you may be called in for an occupational health appointment subject to your current proof that is held on file.

I have read and accept the terms & conditions.

I accept

Request for details of immunisation history

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Request for details of immunisation history

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