TRiM Referral – Encapsulate

Unique ID

Your Name(Required)

Forename Surname

Your Phone Number(Required)

Your Email Address(Required)

Area in which you are referring(Required)

Are you referring an individual or a team?(Required)

Individual

Team

Have they consented to this referral?(Required)

Yes

Name of the person you are referring(Required)

First Last

Name of the team you are referring(Required)

Names of the individuals in the team who require support(Required)

Date of the incident(Required)

Time of the incident(Required)

Brief description of the incident(Required)

This field is for validation purposes and should be left unchanged.

We take your privacy, and the security and confidentiality of healthcare data, extremely seriously. This website has been built with security and confidentiality in mind.

Your IP address is never logged in our database.
Any person identifiable data you submit via this form is stored on a secure database server in England, which only the relevant authorised healthcare professionals can access.
All email notifications containing person identifiable data are sent securely through NHSmail.
Our processes for collecting data via this website have been approved by the Hull University Teaching Hospitals NHS Trust Information Governance Committee.
We are fully compliant with GDPR and the Data Protection Act 2018.
If you have any questions or concerns about this form, please contact the Digital Communications Team.