Client Login Planning Request Form A&D Screening Form

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A&D Screening Form

Fill out this Form for up to 2 donors. If you require more than 2 you will need to fill out the Form again.

Customer / Client / Sponsor
Company Name*
Company Address*
Billing Address (If different)
Company Email*
Person Making Booking*
Company Telephone*
Sentinel Sponsor Number*
Testing Location
Testing Location Address*
Testing Location Postcode*
How many Donors will be attending?*
- 1
- 2
Donor Details
Name
First Last
Date of Birth
National Insurance Number*
Sentinel Number*
Employee Number
Screening Type Required
Select screening type for donor*
- Pre Appointment
- Pre-Sponsorship
- Post Incident
- Periodic
- Unannounced
Second Donor Details
Name
First Last
Date of Birth
National Insurance Number*
Sentinel Number*
Employee Number
Screening Type Required
Select screening type for donor*
- Pre Appointment
- Pre-Sponsorship
- Post Incident
- Periodic
- Unannounced
Phone
This field is for validation purposes and should be left unchanged.

IMPORTANT INFORMATION
For unannounced screenings, the collection officer will arrive on site and request a list of employee numbers who are at work and fall within the testing pool. The collection officer shall randomly select employee / sentinel numbers from the list until the required number of donors has been reached. The collection officer will pass the selection to the site representative who will present the selected individuals for screening. The collection officer will verify the donor number on the donor’s company ID or sentinel card to confirm the donor presented is the individual selected from the list.
CANDIDATE REQUIREMENTS
• Please ensure all donors arrive 10 minutes before the appointment time and ensure they bring the following items when attending:
• Photographic means of identification. Acceptable identification includes a passport, Driving Licence that includes a photograph) or Sentinel card.
• National Insurance Number
• Details of Medication. They will need to provide the names and dose of all medication taken in the last 14 days whether prescription or over the counter medication. We encourage them to bring a copy of their prescription(s) or the medication itself to ensure an accurate declaration.
Please advise all donors not to smoke, use mouthwash or consume either food or drink in the 15 minutes prior to their appointment.
Any non-negative or positives results will automatically be referred to the MRO. Please be aware that these referrals will incur an additional fee of £115 + VAT.
DECLARATION
We confirm that the information provided is accurate and correct and that we agree to pay all fees in advance of the screening date. We also agree to meet any additional costs incurred as a result of non-negative or Positive results.

Get in touch

Tel: 01323 887186 Email: info@prb-consulting.co.uk

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