Vaccination/Immunisation Status:
Referral To Occupational Health Employee
Occupational Health Department
Lenton Hurst, University Park
Nottingham, NG7 2QL
Tel: (0115) 951 4329
Fax: (0115) 951 4328
Email: [email protected]
READ THIS CAREFULLY BEFORE COMPLETING THIS FORM
This form is to be completed by the authorised referring manager unless otherwise indicated. Please complete this
form and return it directly to the University of Nottingham Occupational Health Department, Lenton Hurst, University Park,
Nottingham NG7 2QL.
1. Contact Details
For completion by Referring Manager/authorised person
Your Name .............................................................. Mr/Mrs/Ms/Miss/Dr .................... (BLOCK CAPITALS PLEASE)
Contact Tel No ......................................................... Faculty ...........................................................................
School / Dept............................................................ Division (if appropriate) ...................................................
Position if not line manager..................................... E-mail address ................................................................
Address for us to reply to ....................................................................................................................................
Name of Referred Employee ..............................................................................................................................
Date of Birth .............................. Payroll No .................................. NI Number ....................................................
Address of Employee ..........................................................................................................................................
Contact No for Employee Home ........................................... Mobile No ...............................................................
Job title of Employee ...........................................................................................................................................
Campus/Location of Employee ………………………………. E-mail address……………………………………
2. Vaccination Requirements - For completion by Referring Manager or authorised person
Tick
Reason
Further details
If known, please state the vaccination required...................................
Research work in a laboratory setting involving use of material from
human/primate source
Research work with a specific pathogen for which vaccination is
available
Working in an NHS/clinical setting
Working with animals where vaccination is advised
Other
Date that work will commence if applicable…………………University Project Code……………………………..
Signed …………………………………….…….. Name……………………………………………. Date……………
Referring Manager/authorised person
Document1
August 2013
Document1
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Vaccination/Immunisation Referral Form