This questionnaire has been designed to help us identify if any of the roles in your organisation should be prioritised for a Covid-19 vaccination.

People most at risk from the complications of COVID-19 are being offered the vaccine first. An independent group of experts has recommended that the NHS first offers these vaccines to those at highest risk of catching the disease and of suffering serious complications or dying from COVID-19. This includes older adults in care homes and frontline health and social care workers. At the same time, the vaccine will also be offered to adults who provide regular care for an elderly or disabled person and younger adults in long-stay nursing and residential settings. 

When more vaccine becomes available, the vaccines will be offered to other people at risk as soon as possible and then everyone else in the population. 

This questionnaire will help us identify if any of the roles in your organisation should be considered in the group of frontline health and social care workers and be put forward for vaccination. Face to face contact should only be undertaken where it is absolutely necessary, and where alternative means of contact have been explored.

This form give you the option to include 3 different roles. If you have more than 3 roles please complete a new form for the additional roles.

This data will be collected by Voluntary Action Harrow and shared with Harrow Council & Harrow CCG to establish if your staff / volunteers should be prioritsed for the vaccine. 

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* 1. Organisation Name

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* 2. Organisation Address

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* 3. Contact e-mail

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* 4. Contact name

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* 5. Contact number

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* 6. Role Title

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* 7. How many workers (staff and volunteers) do this role?

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* 8. Does this role involve working with one of the following client groups?

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* 9. How do staff in this role come into contact with people who are clinically vulnerable?

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* 10. Do you have additional role you'd like to submit?

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