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Covid vaccine application form

The Covid vaccine is voluntary but if you are interested in receiving it, please complete this form to capture the personal details that the Vaccine Coordinators require so they can offer you a Covid Vaccine. Completing this form does not commit you to take up the offer.

Who should complete this survey?

This website application form is particularly aimed at capturing new members of our workforce or those who have been on sick or maternity type leave when the original survey was sent out.

This application form is open to ALL primary care optical staff however the LOC has not been informed whether all staff will be offered it or at the same time. It is anticipated that the Optical Practices workforce may only be offered one when there are spare vaccines available on a given day. Therefore it should be noted that access to these vaccines may be at short notice depending on supply. Alternatively, some CCGs are planning ‘staff vaccine days’ though it is unclear when these will be.

Please do not fill in this form if:

  • You have already filled the original survey sent out by NTW LOC at the beginning of January 2021, or
  • You have started receiving the Covid 19 vaccine or anticipate accessing one because you work for a Secondary care Trust along with your Primary care role.
  • If you filled in the original survey, this has been sent to the specific CCG that you work in. You should be contacted directly, in due course. Phone calls are usually from a withheld number.

    Completed the survey but not been contacted yet?

    Please wait until February 2021 before directly informing the LOC that you have not received a vaccine. It is anticipated that Covid Vaccines will be available for the foreseeable future.

    Protecting your personal data

    Any personal information you provide to NTW LOC will be treated with the strictest of confidence. We use modern encryption technology to transmit your data and will use it only to process your information and pass it on to the relevant CCG for the purpose of providing the vaccine; after this, it will be deleted.


    Covid vaccine application form

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    To prevent misuse, only NTW members may complete this form. If you are an optical staff member working in the NTW area and are not a member of the LOC, please apply for membership and log in first.

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