PCT Forms Online

The forms available for download here have been provided by the LPC, PSNC, the PPSA and various PCTs to aid contractors. Queries and requests should be sent direct to the originating organisation.

Forms Online - NHS Southampton

Forms and documents relating to commissioned services are available for download below.

Clinical Governance

Attachment	Size
Adverse Incident Reporting Form	153 KB

Community Pharmacy Audit

Attachment	Size
Community Pharmacy Lithium monitoring audit 2010-2011.doc	195.5 KB
Community Pharmacy Lithium monitoring audit 2010-2011.docx	132.51 KB

Community Pharmacy Signposting

Attachment	Size
Signposting Documents 2010-11	348.88 KB

EHC Service

Attachment	Size
EHC Community Pharmacy Optional Audit.doc	128.5 KB
EHC Community Pharmacy Optional Audit.pdf	129 KB
Appendix E - EHC claim form for PPSA April 2010.doc	152.5 KB
Appendix E - EHC claim form for PPSA April 2010.pdf	65.4 KB
Appendix B - Competencies & Training Framework Version 2 March 2009.doc	51.5 KB
Appendix B - Competencies & Training Framework Version 2 March 2009.pdf	33.9 KB
Appendix C - EHC Consultation Record Form V5 May 2011.doc	185 KB
Appendix C - EHC Consultation Record Form V5 May 2011.pdf	116.61 KB
Appendix D - EHC monitoring form for PPSA April 2010.doc	152.5 KB
Appendix D - EHC monitoring form for PPSA April 2010.pdf	75.84 KB
Appendix F - EHC Referral Form V2 March 2012.doc	46.5 KB
Appendix F - EHC Referral Form V2 March 2012.pdf	68.49 KB

Miscellaneous

Attachment	Size
NHS Southampton Waste_guidance_for_Community_Pharmacy_Feb_2010.pdf	89.56 KB

Multi-disciplinary Audit

Attachment	Size
DCF for MD Audit of Uncollected Items .pdf	77.7 KB
Guidelines for MD Audit of Uncollected Items.pdf	29.62 KB
Methotrexate Shared Care Guideline - May 2007 Approved (3).doc	171.5 KB

Osteoporosis MURs

Attachment	Size
Osteoporosis & Falls MUR Algorithms 21st August.pdf	44.55 KB
Patient feedback form Osteoporosis and Falls MUR.pdf	30.2 KB
Pharmacist Feedback Form Osteoporosis and Falls MUR.pdf	35.84 KB
Osteoporosis MUR Service Overview final August 21st.pdf	984.54 KB
Osteoporosis and Falls MUR service audit.pdf	26.3 KB

Rota Services

Attachment	Size
FP36 (Oct 06 onwards).pdf	23.84 KB

Smoking Cessation

Attachment	Size
Appendix B Pharmacy Smoking Cessation Monitoring Forms Triplicate Pad 1.4.2010.doc	269 KB
Appendix C Pharmacy Smoking Cessation Monitoring Form as an example- not to be used 1.4.2010.doc	79.5 KB
SOP_for_submitting_the_claim_form_and_monitoring_documents final.pdf	13.72 KB
SOP for Smoking Cessation 4.5.2010.doc	40.5 KB
Smoking_Cessation_Local_Enhanced_Service_Agreement 2011 to 2012 final 4.5.2011.doc	199.5 KB
Prescription_Charge_Letter for 1.4.2012_(PHARMACY_ONLY).doc	127 KB
Smoking_cessation_Protocol_for_Community_Pharmacies 27.3.2012 final as approved 3.4.2012.doc	265.5 KB
Contract_variation_letter_to_community_pharmacist_Re_Smoking_Cessation_3.4.2012_Final[1].doc	184.5 KB
Claim_Form_for_Smoking_Cessation_Advice_and_NRT_2011-2012 17.4.2012 onwards.doc	216 KB
Claim_Form_for_Smoking_Cessation_Advice_and_NRT_2011-2012_for_6. 2.2012 to 16.4.12.doc	213.5 KB

Forms Online - NHS Hampshire

Forms and documents are now available on the NHS Hampshire webpage 'Pages for Primary Care' (P4PC).

The Pharmaceutical Needs Assessment can be found by clicking here.

The Joint Strategic Needs Assessment is available by clicking here .

Documents relating to other non-commissioned services such as locally targeted MURs are provided below.

Alcohol Service

Attachment	Size
Alcohol brief advice tool.pdf	62.94 KB
Alcohol Client Form.pdf	40.63 KB
Pharmacy IBA implementation plan FINAL Nov 2010.pdf	115.96 KB
ESMAQ User Guide.pdf	1.13 MB

Bowel Cancer Awareness

Attachment	Size
May Newsletter.pdf	59.49 KB

CRB Documents

Attachment	Size
Address History Template.doc	87.5 KB
Applicants Guide to Completing the CRB Application Form.pdf	483.8 KB
Code of Practice.pdf	372.13 KB
Disclosure Access Category Codes.doc	117 KB
Evidence of Identity Template.doc	64.5 KB
Guidance on the Completion of Disclosure Application Forms.doc	120.5 KB
Guidance on Unspent Criminal Convictions.doc	111 KB
Vetting and Barring Scheme F.A.Q_low_res.pdf	1.22 MB

Dermatology MUR Service

Attachment	Size
Aqueous Cream Paper.pdf	259.32 KB
Concordance Self-assessment tool.pdf	272.54 KB
Dermatology MUR Audit.pdf	56.49 KB
Patient Feedback Form.pdf	162.33 KB
Patient Flow Chart.pdf	59.95 KB
Portsmouth Drug Formulary Dermatology.pdf	50.41 KB
Service Aims and Objectives.pdf	90.25 KB

EHC Service

Attachment	Size
Appendix D - EHC monitoring form for PPSA April 2008.pdf	26.77 KB
Appendix D - EHC monitoring form for PPSA April 2008.doc	54 KB
Appendix C EHC Consultation Record Form April 2008.pdf	46.66 KB
Appendix C EHC Consultation Record Form April 2008.doc	82 KB
Appendix E - EHC claim form for PPSA April 08.pdf	16.88 KB
Appendix E - EHC claim form for PPSA April 08.doc	60 KB

Guidelines

Attachment	Size
Antibiotic Prescribing Guidelines.pdf	324.19 KB
Bruising in babies.pdf	18.65 KB
HPCT Depression Guidelines printed 11-06.pdf	111.03 KB
Persistent Pain Leaflet.pdf	259.51 KB
Repeat Dispensing Good Practice Guidelines V5 Sept 07.pdf	30.55 KB
Sexually Active Young people protocol 06 08.pdf	137.19 KB
Waste Management Guidelines July 11 pdf.pdf	82.96 KB

Hampshire Pharmacy Needle Exchange

Attachment	Size
Pharmacy Needle Exchange Client Menu.pdf	33.44 KB
Pick & Mix guide to reporting on ESMAQ.pdf	418.57 KB

Miscellaneous

Attachment	Size
Medicines Management Team (June 09).pdf	14.49 KB
MUR Consent Request form v4 Oct 07.pdf	20.3 KB
MUR Prem2 (off site) form (HPCT).pdf	20.3 KB
Signposting Directory 2009.pdf	139.88 KB
FP36 (Oct 06 onwards).pdf	23.84 KB

Palliative Care

Attachment	Size
Palliative Care Pharmacies_Drug_List_August_2011.pdf	35.72 KB
palliative_care_pharmacies_for_p4pc[1].pdf	24.05 KB

Respiratory MUR Service

Attachment	Size
GOSPORT RESPIRATORY - 2 TONE ORDER FORM.pdf	90.66 KB
MUR GP Referral Form.pdf	17.07 KB
Patientfeedbackform.pdf	162.33 KB
PatientFlowDiagram.pdf	44.76 KB
Respiratory_MUR_audit.pdf	49.78 KB
Respiratory_MUR_audit.xls	28 KB

Smoking Cessation

Please check regularly as new and updated forms added

Attachment	Size
NRT Drug claim form + new 15mg inhalators NOV 2011.xls	418 KB
Quit4Life Service Provision Update for Pharmacies Nov 2011 (2).doc	110.5 KB
SUMMER_&_AUTUMN_2011_Pharmacy_Newsletter.doc	1.59 MB
Appendix H Claim form Pharmacy LES 1011 20 per cent VAT.doc	35 KB
Client monitoring form - LES Nov 2010.pdf	261.4 KB

Forms Online - NHS Isle of Wight

Forms and documents relating to our commissioned services are available for download below. We have recently taken the time to convert all the claim forms for PDF format so that they can be downloaded onto any computer system and printed using Adobe Reader - follow the link to the download and install the Reader program.

Working on the Island

The PCT has produced a comprehensive introduction to working and living as a pharmacist on the Isle of Wight. Suitable for residents, potential residents and visiting locums alike, it gives the low down on what's available for entertainment and activities out of hours together with a comprehensive guide to community pharmacy and the services we offer through them on the Island. You can download a copy below.

Island Pharmacy Flu Service Evaluation

Pinnacle Health Partnership worked in collaboration with the PCT to evaluate the NHS flu vaccination service provided through community pharmacy in the 2010/11 season to investigate patient opinions and outcomes. The document can be downloaded from the flu service section below.

Attachment	Size
Pharmacy On The Island (May 2009).pdf	1.15 MB

New Claim Arrangements from April 2012

IOW Blank Monthly Claim Form with Weekly Rota 2012-13 .pdf

The NHS reorganisation means that there are new arrangements for the claim of services provided by Island pharmacies.

Attachment	Size
Transition to PPSA Letter 29 Mar 2012.doc	65.5 KB
IOW Blank Quarterly Claim Form 2012-13 from April 2012.pdf	38.03 KB
IOW Blank Monthly Claim Form with Weekly Rota 2012-13 (from April 2012).pdf	43.54 KB

Alcohol Awareness Scratchcard

Attachment	Size
Alcohol Units Poster.pdf	353.38 KB
Scratchcard Counter Sheet.pdf	285.75 KB

COPD Assessment Service

To support World COPD Awareness Day (16th November), we are offering free lung checks at some of our pharmacies using a Pulmolife device. Although activity will be focussed around this day, the service will be valuable throughout the year to raise awareness of both COPD and the availability of NHS Stop Smoke services.

Attachment	Size
Lung Health Check Questionnaire.pdf	28.36 KB
PHARMACY CHRONIC OBSTRUCTIVE PULMONARY DISORDER v2.pdf	26.03 KB
StopSmokeAndCOPDPresentation.pdf	403.28 KB

Child Protection

Attachment	Size
Child Protection Flow Chart.pdf	46.41 KB

Chlamydia Screening and Treatment Service

Attachment	Size
Chlamydia Audit.pdf	10.89 KB
Chlamydia Leaflet (FPA).pdf	1.3 MB
Chlamydia Test Kit Order Form (October 2011).pdf	100.31 KB
Treatment Form (October 2011).pdf	108.81 KB

Condom Distribution Scheme

Attachment	Size
CDS Contents List.pdf	62.68 KB
CDS_Registration_Form_1.2_October_2011.pdf	57.7 KB
Condom Distribution Guidance.pdf	137.53 KB
Condom_Order_Form_(Quarterly)_1.2_October_2011.pdf	104.74 KB
Fraser assessment CDS.pdf	12.01 KB

Dementia Service

Attachment	Size
IOW Dementia MUR Steve Bleakley Nov 2010.ppt	628.5 KB

Electronic Prescription EPS Support

Attachment	Size
EPS Audit.pdf	26.92 KB
NHS Isle of Wight - Assigning a Position in UIM .pdf	1.15 MB
Registration Authority Policy 2011 Final.pdf	105.54 KB
Step Gude to Change Passcodes.pdf	1.12 MB
Step Gude to Unblocking a Smartcard.pdf	872.73 KB

Emergency Hormonal Contraception

Attachment	Size
EHC Consultation Form.pdf	18.24 KB
EHC Client Leaflet 0710.pdf	10.91 KB
EHC Fraser Assessment.pdf	3.58 KB
EHC Quarterly Audit Form.pdf	10.47 KB
EHC Reception Protocol.pdf	51.33 KB
EHC Signposting.pdf	38.83 KB

First Contraception Service

Attachment	Size
Cerazette PGD.pdf	40.71 KB
CP awareness posterApr10.pdf	46.41 KB
Current Patient advice sheet after consultation.pdf	91.17 KB
FPA Leaflet POP.pdf	609.59 KB

Green Bag Scheme

Attachment	Size
Briefing for clinical staff Green Bags v2 1.pdf	256.12 KB
POSTER Patient's own medicines green bag - 23 June 2010.pdf	880.53 KB

Healthy Living Pharmacy

Attachment	Size
Isle of Wight HLP Prospectus.pdf	1.56 MB
Isle of Wight HLP Foundation Document.pdf	259.53 KB

Medical Guidelines IoW

Omnitrope Support Service

Attachment	Size
Client Information Leaflet.pdf	359.97 KB

Osteoporosis Service

Other Useful Forms and Information

Attachment	Size
PLG Claim form for attendance.pdf	19.69 KB

Out of Hours Emergency Supplies

Attachment	Size
Process to follow.pdf	26.47 KB

Out of Hours and Rota

Attachment	Size
Out of Hours Repeat Medication Request form 2011.pdf	40.17 KB
Pharmacy Rota 2011.pdf	43.51 KB
Special day Rotas.pdf	42.37 KB

PCT Fee Claim Forms

Attachment	Size
Not To Dispense Claim Form 0710.pdf	15.2 KB
Platinum Points Claim Form.pdf	14.78 KB
Return to Stock Claim Form 0710.pdf	7.77 KB
Blank Quarterly Claim Form 2012.pdf	71.66 KB
Blank Monthly Claim Form OOH Weekly Rota revised.pdf	99.86 KB

Paediatric Asthma Review Service

Attachment	Size
MUR Service overview.pdf	470.74 KB
Audit Form.pdf	20.9 KB
Carer Feedback.pdf	111.92 KB
Pharmacist Feedback Form.pdf	28.04 KB
GP briefing.pdf	29.46 KB
HCP Feedback Form.pdf	16.72 KB

Palliative Care and Just in Case

Attachment	Size
JIC - District Nurse Form.pdf	84.95 KB
JIC - District Nurse Guide.pdf	27.84 KB
JIC - Leaflet for Patients and Carers.pdf	26.42 KB
JIC - Service Overview.pdf	39.2 KB
JIC - The 3 Steps Version.pdf	18.82 KB
Palliative Care Audit Form.pdf	11.08 KB
Palliative Care Stock List (CD and non-CD).pdf	29.3 KB

Reablement

Attachment	Size
Medicines Chart.pdf	7.08 KB
Reablement - Assessment June 2011.pdf	200.82 KB
Reablement Service Description.pdf	531.53 KB

Respiratory MUR

Attachment	Size
ACT Test for Asthma.pdf	65.79 KB
CAT Test for COPD.pdf	35.62 KB

Screening and Vaccination Service

Attachment	Size
Audit - Hepatitis B Vaccination.pdf	19.47 KB
Audit of Dry Blood Spot Testing.pdf	34.32 KB
BBV and Syphilis testing LES vGW.pdf	22.3 KB
Clinical - Hepatitis Disease Information.pdf	75.3 KB
Example - Dry Blood Spot Test Order Form.pdf	221.53 KB
Hep B vaccination PGD.pdf	36.23 KB
Leaflet - Patient advice sheet after consultation.pdf	59.54 KB
LES Agreement.pdf	22.3 KB
Notification to Sexual Health and GP.pdf	60.63 KB
Patient Questionnaire Dry Blood Spot Test.pdf	23.48 KB
PGD Hep B Vaccination Pharmacists HIV extension.pdf	36.23 KB
PGD Hepatitis B Vaccination.pdf	36.23 KB
Screen - Leaflet - About hep B and C.pdf	1.42 MB
Screen - Leaflet - Just diagnosed - hep B.pdf	164.15 KB
Screen - Leaflet - Just diagnosed - hep C.pdf	191.79 KB
Service - At Risk Criteria.pdf	37.3 KB
Service - Dried Blood Spot Flow Chart.pdf	16.96 KB
Service - Dry Blood Spot Testing Protocol.pdf	34.3 KB
Service - Example of results slip.jpg	889.82 KB
Service - GP Notification of Hep B Vaccination.pdf	37.62 KB
Service - Hepatitis B Service Stakeholder Letter.pdf	33.99 KB
Service - Hepatitis B Vaccination Consultation Form.pdf	18.71 KB
Service - Hepatitis B Vaccination Service SOP.pdf	18.61 KB
Service - IDAS Referral Form Hep B service.pdf	57.07 KB
Service - Needle Stick Injury Suggested Procedure.pdf	18.08 KB
Service Overview.pdf	85.43 KB
Signposting Document.pdf	64.33 KB

Seasonal Influenza Vaccination and Influenza Protocols

Attachment	Size
Anaphylaxis PGD.pdf	44.2 KB
Audit pad updated.pdf	14.74 KB
Seasonal Flu Community Pharmacy Service Report 2010 - v1.4c Final.pdf	1.98 MB
Pharmacist protocol for supplying Tamiflu.pdf	28.45 KB
Seasonal Influenza LES.pdf	29.74 KB
Pharmacist protocol for supplying Relenza.pdf	22.62 KB
H1N1 Audit Pad.pdf	24.81 KB
Patient Information Leaflet.pdf	52.81 KB
Isle of Wight Flu PGD Sept 2011.pdf	192.58 KB
H1N1 Patient information leaflet.pdf	33.03 KB
H1N1 Pharmacy Based Collection points.pdf	17.95 KB

Stop Smoke Support

Attachment	Size
Prescription Price Letter.pdf	40.49 KB
NRT Order Form December 2011.pdf	130.72 KB

Substance Misuse Forms

Attachment	Size
Needle Exchange Form 0712.pdf	117.65 KB
Supervised Consumption Claim Form.pdf	17.36 KB

Tandem Project

Attachment	Size
Tandem Project Claim Form A.pdf	19.7 KB

Trimethoprim PGD

Attachment	Size
Trimethoprim Doctor Letter.pdf	5.74 KB
Trimethoprim Interview Form.pdf	17.03 KB
Trimethoprim Patient Leaflet.pdf	7.88 KB
Trimethoprim Signposting.pdf	38.62 KB

Forms Online - NHS Portsmouth City

Forms and documents relating to commissioned services are available to download below.

Electronic Prescription Service (EPS)

Attachment	Size
Communication Plan.pdf	111.71 KB
Continuity Guidance (Appendix 1).pdf	189.25 KB
Continuity Guidance (Appendix 2).pdf	189.25 KB
Continuity Guidance (Appendix 3).pdf	33.48 KB
Continuity Guidance (Appendix 4).pdf	15.51 KB
Continuity Guidance.pdf	163.52 KB
Dispensing Token Plan.pdf	150.56 KB
Nomination Policy.pdf	111.46 KB

Safeguarding

Attachment	Size
Safeguarding Adult Policy Appendix 2 - Concern Form 3rd draft 9-2008.pdf	187.59 KB

PPSA Forms

Download Forms

The forms available for download here have been provided by the LPC, PSNC, the PPSA and various PCTs to aid contractors. Queries and requests should be sent direct to the originating organisation.

All queries concerning this page and its content should be directed to Sarah Ralph.

Change of Hours

Attachment	Size
Application to Amend Core Hours.doc	139.5 KB
Application to Amend Supplementary Hours.doc	138 KB
Example Change of Hours Form.pdf	94.9 KB

Rota Claims

Attachment	Size
FP36 (Oct 06 onwards).pdf	23.84 KB

Miscellaneous

Attachment	Size
Contract Application Form (Mar08).pdf	50.01 KB
Contract Application Form (Mar08).doc	160.5 KB