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

This form is to be completed by patient facing colleagues who are taking part in our asymptomatic staff testing programme. Please complete this form after doing your swab and record your result. Swabs should be undertaken twice a week and three days apart.

Step 1 of 4

About you
I am a * REQUIRED
- GHC employee with a GHC email address
- I work on behalf of GHC but don't have a GHC email address

As you have a GHC email address please use the covid portal to record your result. Visit: https://app.glos-care.nhs.uk/covidportal

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

: Hours

Minutes
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

If you have had an invalid result, please do a second test and record the result from that test.
We will attempt to contact you 2 times within a 2 day period to arrange your test. If we are unable to contact you we will send you a text about what happens next. Calls from our service may appear as a withheld number.

Covid 19 Information

Step 1 of 4

About you

About your test

Request a PCR Test