Asymptomatic Staff Testing – Lateral Flow Device Results Form > Gloucestershire Health and Care NHS Foundation Trust

Name * REQUIRED
First Last
Gender * REQUIRED
Date of birth * REQUIRED
NHS number
Home Postcode * REQUIRED
Email * REQUIRED
Date Entry * REQUIRED
Your job location * REQUIRED
Which Ward/Service/Department/Team do you work in?
About your test
About this test * REQUIRED
- This is my first submission
- I have submitted results before
Date of test * REQUIRED
Time of test
: HH
MM
Test result * REQUIRED
- Positive
- Negative
- Invalid
Test lot number * REQUIRED
This can be found on your device wrapper
Request a PCR Test
Please self isolate until you have had a PCR swab and received your result. Your household members will need to self isolate too. Information about self isolating can be found here: https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-households-with-possible-coronavirus-covid-19-infection
Your personal mobile number * REQUIRED
This will be used to share your results with you
Your email

If you would like a copy of this test request emailed to you
Your job role * REQUIRED
Your line manager's name * REQUIRED
First Last
Your line manager's email address * REQUIRED
By completing this form you are consenting to a positive result being shared with your employer as it is a notifiable disease * REQUIRED
- I consent to a positive result being shared

About you