TB Refusal

Tuberculosis Unable/Refuse To Be Vaccinated

CONFIDENTIAL

The National Institute for Health and Clinical Excellence (NICE) has published guidelines on the ethical considerations of infectious diseases, which recommends that all healthcare workers undergo screening if they feel they have put themselves at risk. Employees new to the NHS (including those individuals working in Health and Social Care if based in Northern Ireland) and who will be working with patients or clinical specimens should not start work until they have completed a TB screen or health check. Should you refuse or be unable to undertake a BCG vaccination post negative Mantoux screening, you must complete this form detailing the specific reason you are unable/refusing to be vaccinated.

1 Personal Details

Personal Information

First Name

Last Name

Phone

Address *

Address Line 1*

Write Here

Town*

Write Here

County*

Write Here

Postcode*

Write Here

GP Address *

GP Name

Address

County

Town

Postal Code

The reason you are unable/refusing to be vaccinated:

2 Declaration

DECLARATION

I now confirm that I am unable/refusing to have a BCG that is required under the terms and conditions for the supply of temporary staff to the NHS and Health and Social Care (Northern Ireland). I also confirm that I have been informed of the relevant risks and the symptoms of infection.

Name

Signature Pad Title

Multiline Textarea Title*

Write Here

Tuberculosis Unable/Refuse To Be Vaccinated

Personal Information

DECLARATION

Signature Pad Title

Your form has been submitted