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Boots Colleague Healthcare Workers Questionnaire

You have been identified by Boots or the NHS/CCG who have commissioned the service you will be providing as needing to be vaccinated in line with healthcare worker vaccinations. You now need to be assessed by Doctorcall in view of your vaccination history and services you will be offering.  In order to fill in the following you will require details of your vaccination history (with dates) for tuberculosis, mumps, measles, rubella and chickenpox.

In order for us to advise you of your nearest network clinic and give you details of how to arrange your appointments we need you to register with Doctorcall by completing the form below.


Title
First Name
Surname
Gender
Date of Birth
Home Address
Please include your postcode.
Email Address
Please provide an email address to which you are happy to receive personal information
Daytime Telephone
Mobile Telephone
Staff Number
Question 1. Tuberculosis

Are you immune to Tuberculosis?

You will require documentary evidence of immunity. Please answer question 2.
You will need to have a BCG vaccination. Please answer Question 3.
Question 2.

Do you have documentary evidence of immunity to Tuberculosis?

Please answer Question 3.
You will require an immunity test for Tuberculosis.
Question 3. Measles, Mumps & Rubella (MMR)

Are you immune to MMR?

You will require documentary evidence of immunity. Please answer question 4.
You will need to have two separate doses of the MMR vaccine. Please answer Question 5.
Question 4.

Do you have documentary evidence of having received two doses of MMR or of having positive antibody tests for measles and rubella?

Please answer Question 5.
You will require an immunity test for MMR.
Question 5. Varicella (Chickenpox)

You may have had chickenpox or shingles in either childhood or adult life. If you have, you will not require varicella vaccination or testing but if not, you will be tested for immunity.

Are you immune to Varicella?

You will not require varicella vaccination or testing. Please answer Question 6.
You will require an immunity test for varicella. Please answer Question 6.
Question 6. Hepatitis B

Are you immune to Hepatitis B?

You will require documentary evidence of immunity. Please answer question 7.
Please answer Question 8.
Question 7.

Do you have documentary evidence of immunity to Hepatitis B?

You do not need to answer any further questions. please press the submit button at the bottom of the page.
You will require an immunity test for Hepatitis B. You do not need to answer any further questions.
Question 8.

Have you had a complete course of hepatitis B vaccinations through Boots Hepatitis B Vaccination Services for Boots Colleagues or another provider and now require a Hepatitis B Immunity test?

You do not need to answer any further questions. Doctorcall will contact you shortly with instructions for arranging your Hepatitis B Immunity test.
You will need to complete your course of Hepatitis B vaccinations. Please answer Question 9.
Question 9.

Have you had any Hepatitis B vaccinations in the past?

Please answer Question 10.
You do not need to answer any further questions. Contact your nearest Boots travel pharmacy and make an appointment to access the Boots Hepatitis B Vaccination service for Boots Colleagues.
Question 10.

Have you had an anaphylactic reaction to the ingredients of hepatitis B vaccine in the past?

You should not have another hepatitis B vaccination. You do not need to answer any further questions.
Please answer Question 11.
Question 11.

Are you part way through a course of hepatitis B vaccinations through Boots Hepatitis B Vaccination Services for Boots Colleagues or another provider?

You do not need to answer any further questions. You should complete your course with Boots and contact Doctorcall at the appropriate time to arrange your immunity test.
You will need to complete your course of Hepatitis B vaccinations. Please answer Question 12.
Question 12.

When have you had Hepatitis B vaccinations previously?

Please provide details of any Hepatitis B vaccinations you have had, with dates.
Job Title

Additional Information

1 to 4 months after completing a primary course of Hepatitis B vaccinations, you will be given a Hepatitis B immunity test. Once immunity has been established you will require booster at 5 years.

5 years after completing a primary course of Hepatitis B Vaccinations, you should arrange for a 5 year booster from a Boots Travel Vaccination Pharmacy.

If you had vaccinations in the past as part of a primary course of Hepatitis B vaccinations which was not completed, you may need to start the primary course again. Doctorcall will advise depending upon the information you have provided.

If you have any queries, please contact the Doctorcall Medical Assistance Team by email at Boots@doctorcall.co.uk, or by fax on 0161 834 5827 quoting your full name and date of birth in all correspondence.

 

I declare that to the best of my knowledge and belief, the information contained herein is complete and true.