"*" indicates required fields Name * REQUIRED First Last Email Preferred phone numberEmployee number Line manager Directorate * REQUIREDPlease select...Adult CommunityCYPSHospitalsSpecialist Service/Urgent CareOtherTeam / Department * REQUIRED Bank is its own teamBase * REQUIRED Role * REQUIREDPlease select...Additional Clinical ServicesAdditional Professional Scientific and Technical StaffAdministrative and Clerical StaffAllied Health ProfessionalEstates and Ancillary StaffHealth Care ScientistMedical and Dental StaffNursing and Midwifery StaffStudentDoes the person to be tested regularly perform Aerosol Generating Procedures (AGPs) (1+ a week)? * REQUIRED Yes No Is this a Working Well referral? * REQUIRED Yes No Examples of AGPs: Intubation/Extubating related procedures Manual Ventilation Dental procedures (e.g. high-speed drilling) Non-Invasive Ventilation (e.g. CPAP & BiPAP) Is the person to be tested currently pregnant? Yes No Has the person failed on all available masks via the Qualitative (Bitter Sweet) Method and is a regular AGP performer? * REQUIRED Yes No Add a second person to this request? * REQUIRED Yes No Person 2Name * REQUIRED First Last Email Preferred phone numberEmployee number Directorate * REQUIREDPlease select...Adult CommunityCYPSHospitalsSpecialist ServiceUrgent Care/OtherBase * REQUIRED Line manager Team / Department * REQUIRED Bank is its own teamRole * REQUIREDPlease select...Additional Clinical ServicesAdditional Professional Scientific and Technical StaffAdministrative and Clerical StaffAllied Health ProfessionalEstates and Ancillary StaffHealth Care ScientistMedical and Dental StaffNursing and Midwifery StaffStudentDoes the person to be tested regularly perform Aerosol Generating Procedures (AGPs) (1+ a week)? * REQUIRED Yes No Examples of AGPs: Intubation/Extubating related procedures Manual Ventilation Dental procedures (e.g. high-speed drilling) Non-Invasive Ventilation (e.g. CPAP & BiPAP) Is this a Working Well referral? * REQUIRED Yes No Is the person to be tested currently pregnant? Yes No Has the person failed on all available masks via the Qualitative (Bitter Sweet) Method and is a regular AGP performer? * REQUIRED Yes No Add a third person to this request? * REQUIRED Yes No Person 3Name * REQUIRED First Last Email Preferred phone numberEmployee number Directorate * REQUIREDPlease select...Adult CommunityCYPSHospitalsSpecialist ServiceUrgent Care/OtherBase * REQUIRED Line manager Team / Department * REQUIRED Bank is its own teamRole * REQUIREDPlease select...Additional Clinical ServicesAdditional Professional Scientific and Technical StaffAdministrative and Clerical StaffAllied Health ProfessionalEstates and Ancillary StaffHealth Care ScientistMedical and Dental StaffNursing and Midwifery StaffStudentDoes the person to be tested regularly perform Aerosol Generating Procedures (AGPs) (1+ a week)? * REQUIRED Yes No Examples of AGPs: Intubation/Extubating related procedures Manual Ventilation Dental procedures (e.g. high-speed drilling) Non-Invasive Ventilation (e.g. CPAP & BiPAP) Is this a Working Well referral? * REQUIRED Yes No Is the person to be tested currently pregnant? Yes No Has the person failed on all available masks via the Qualitative (Bitter Sweet) Method and is a regular AGP performer? * REQUIRED Yes No CAPTCHA