Vaccination Questionnaire - Trinity Hospice

By answering these questions, you'll help us to monitor who has been vaccinated this winter against flu, whether in the hospice or externally.

Please complete this form once you have had your flu vaccine to let us know where you had it. All vaccinated colleagues will be added to a prize draw to win a £50 Love to Shop Voucher.

Please also use this form if you do not intend to you get your winter flu vaccine. It will help us identify key learnings.
Name*
First Last
Which department do you work in?*
Where did you receive your flu vaccine?*

At Trinity as part of the winter vaccine programme

At the Vaccine Van parked outside Trinity Hospice on Friday 17th October

Externally, at a doctors' surgery, pharmacy or other
If you feel comfortable, please explain why you don't intend to get your flu vaccine.

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© Trinity Hospice & Palliative Care Services. A Company Limited by Guarantee. Registered in England. Registration No. 01537498. VAT Reg. 219721995. Registered as a Charity No. 511009

Registered Office: Trinity Hospice & Palliative Care Services Ltd, Low Moor Road, Bispham, Blackpool, FY2 0BG | 01253 358881 | trinity.enquiries@trinityhospice.co.uk

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