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