COVID-19 and Flu Risk Assessment Calculation
    We now know that Covid-19 has a disproportionately high impact among some groups of people. A number of bank workers may have unrecognised health conditions and may therefore be more vulnerable.
    For those working via ICG Medical Ltd agency brands a risk assessment must now be completed and if required will be submitted to the Trusts/organisation the nurse wishes to work in.
    The data on this form will be shared with the Trusts/organisation only with the nurses written approval and individual elements can be redacted if there are concerns about confidentiality. Should the nurse not wish the data to be shared then it cannot be shared and the nurse will not be offered work at any Trust/organisation where the required risk assessment outcomes cannot be provided.
    Ensure you read the questions and take your time whilst completing this risk assessment and provide a true overview of your health and well being. Dependant on your calculated score from the completion of this form, you may be contacted by a member of the clinical team to discuss the risk assessment.
    Each Trust will determine which category of risk it will accept, this is not in the control of ICG Medical or its agency brands. Currently there is variation between the Trusts as to which level of risk they will accept or not.
    If you develop changes towards your overall health and wellbeing after completing this Risk Assessment, please contact Emma.Marshall@icg-medical.com to request another Risk Assessment.
    What is your full name?
    Email
    Today's Date
    Primary Brand
    Job Role
    Speciality
    Have you been FFP3 fit mask tested? If you have answered 'yes' to the above, where were you tested? Which mask are you tested to wear?
    Age Group
    Sex assigned at birth
    Do you belong to a Black, Asian or other minority Ethnic Group?
    What is your BMI? If you are unsure on how to calculate your BMI accuratly, please visit the URL below and follow the instructions given: https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/

    Are you/could you be pregnant ?
    If you have answered 'yes' to the above questions, how many weeks pregnant are you?
    Have you received a flu vaccination within the past 12 months?
    Do you have/suffer from any of the below conditions:

    Have you received your 1st Covid vaccination? Date of 1st Covid Vaccination
    Have you received your 2nd Covid vaccination? Date of 2nd Covid Vaccination
    Have you had your Covid Booster vaccination? Date of Covid Booster vaccination
    Proof of NHS Covid Pass

    Do you have any other concerns related to your ability to undertake the care required for COVID patients? (include Carer responsibilities, psychological concerns following Covid bereavement or family members who were cared for in ITU, or other conditions which you believe make you more susceptable to poor outcomes from COVID 19)

    Please sign below to confirm the details in this form are correct and true:
    Date: