Notification of Self Isolation

In line with DHSC guidance, you can take special leave with pay for the recommended period of self-isolation or sickness with COVID-19. Your health and safety is our priority and this special pay provision is in place to ensure you are not financially disadvantaged during the COVID-19 pandemic. You will receive the normal shift payment for pre-booked shifts during any period of self-isolation or sickness with COVID-19. You should have already cancelled your shifts with the reason of Self-Isolation. The impacted shifts will be automatically released on your behalf.

ESR Number on any NHS Professionals payslip (e.g. 12345678 or 12345678-2):

First name:

Last name:

Mobile phone:

Email address:

Please confirm the NHS Trust where you were booked to work:

Please confirm your isolation start date (after 20 March 2020):

**Please enter date format as dd/mm/yyyy if not prompted**

Please confirm your isolation end date:

**Please enter date format as dd/mm/yyyy if not prompted**

Please select your reason for Self Isolation:

Do you have access to a car?

You may only attend a COVID-19 Regional Testing Centre via car with a known registraion and only with members of your household in the vehicle. Please click HERE for further information about COVID-19 Regional Testing Centres.

Knowingly submitting this form with the intention of claiming payments fraudulently is a criminal offence and subject to investigation and/or prosecution. Where we have concerns that claims have been made in circumstances where you are not required to self-isolate, where you are not sick for COVID-19 related reasons, or you book into shifts with no reasonable prospect of working that shift, the matter may be referred to the NHS Counter Fraud Authority. It would also be subject to separate disciplinary proceedings, which may result in your registration being restricted pending investigation and/or terminated.