The contents of this form will be treated in absolute confidence

Boots Colleague Needle-Stick Aftercare Questionnaire

You have had a needle-stick injury with a used needle or sharp and, as instructed in the Boots process, attended A&E in the first instance. Further follow-up has been recommended and you will need to contact Doctorcall for further assessment. In order to complete an assessment you will require details of your Hepatitis B vaccination history (with dates).

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
What date did the needle stick injury occur?
Question 1.

Please give details of the treatment you received in the Hospital A&E for your needle-stick injury?

Question 2.

Are you immune to Hepatitis B?

You will have completed a primary course of Hepatitis B vaccinations. You do not need to answer any further questions. Doctorcall will contact you shortly with instructions for your needle-stick aftercare.
You will need to complete your course of Hepatitis B vaccinations as part of your needle-stick aftercare. Please answer Question 3. Doctorcall will contact you to arrange appointments.
Question 3.

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

You should not have another hepatitis B vaccination.
Please answer Question 4.
Question 4.

When have you had Hepatitis B vaccinations previously?

Please provide details of any Hepatitis B vaccinations you have had, with dates.
Question 5.

Is there any further information given to you at A&E that we should know?

Doctorcall will contact you to arrange follow up appointments.
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 and treat the Hepatitis B vaccination you received in A&E as the first vaccination in the course. 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.