Seasonal Flu Vaccinations Request Form

Please complete the details below to request a flu vaccine voucher. Once the completed form has been received it will be processed and a voucher will be sent out to you within 48 hours.

For the employee to complete:

Employee Name:

Employee Number:

Department:

Address for the voucher to be sent to (can be home or work)

Signed:

Date:

Please ensure that you state the full address in order to minimise any delay in receiving your

voucher

HR use only

Received:

Date:

Voucher sent:

Y N

Date sent:

Signed: Date:

Print name:

This form needs to be returned to the HR Department, Southgate Campus,

High Street, London N14 4BS to be processed or it can be scanned and emailed to Charleene.Davies@barnetsouthgate.ac.uk.