Flu Vaccination Record Form 2022/23

To be completed if you have been vaccinated outside of SaTH.

Last updated: 18 October 2022 at 11.26am

Your information

I understand that by submitting this information it will form part of anonymised flu uptake data reporting.

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Employee Number*(Required)

Job Title(Required)

Department(Required)

Where Were You Vaccinated?(Required)

e.g. GP practice or local pharmacy

When Were You Vaccinated?(Required)

* Please note if correct Employee Number is not provided it will not be possible to issue a voucher.