Standards › Standard 2E › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WRK-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.3
At a glance
- Check each staff member’s vaccination status before the first clinical shift.
- Offer the required vaccinations listed for the area they work in.
- Record each dose and the date of the next due dose.
- Check status again each year.
- Stop and get help straight away if: a staff member works in a clinical area without a required vaccination and without a recorded exemption.
1. Purpose
To protect staff and patients by keeping required vaccinations current for each role [EC].
2. Scope
| Applies to | All workforce members in clinical or patient-facing roles |
| Locations | All services |
| When | At appointment, then yearly, and on any new requirement |
| Does not apply to | Vaccines the staff member chooses for personal travel |
3. Definitions
| Term | Meaning |
|---|---|
| Required vaccination | A vaccination set by the organisation for a role, based on national guidance |
| Exemption | A written decision by occupational health that a vaccination is not suitable for the person |
4. Background
Vaccination protects staff and the patients they treat. A current list is the only way to show that the protection is in place.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Occupational health lead | Sets the required list and reviews exemptions | Occupational health |
| Human resources lead | Checks status at appointment | HR administration |
| Line managers | Do not roster a staff member without a current status | Management |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Vaccination record for each staff member | Current | Reviewed each year |
| Required vaccination list for each role | Current, approved by occupational health | Dated within the last 12 months |
7. Safety
- A person without immunity to a required vaccine is not placed in an area where that infection is a known risk.
8. Before you start
- Confirm the required list for each role.
9. Procedure
Step 1. Check status.
- Compare the record with the required list for the role.
- Mark each vaccine as current, due or missing.
Key point: A missing dose is a risk, not an admin task.
Step 2. Offer the vaccine.
- Offer each missing or due vaccine at occupational health.
- Give the staff member the information on the vaccine.
Key point: Offer is documented, even if refused.
Step 3. Record the dose.
- Enter the dose, batch number and date.
- Set the next due date.
Key point: Batch numbers are needed if a reaction happens.
Step 4. Handle refusal or exemption.
- If refused, record the refusal and the risk discussion.
- If exempt, occupational health records the exemption with a review date.
Key point: A refusal must be recorded, and the staff member’s role must be reviewed.
10. Decision points
- If a staff member refuses a required vaccine, the service manager decides on a change of duties to a non-exposed role.
11. Special situations
| Situation | Action |
|---|---|
| Outbreak | Occupational health advises on urgent vaccination of staff in the affected area. |
12. Escalation
- A staff member without a required vaccine in a clinical role is reported to the chief executive.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Staff with required vaccinations current | 100% | Yearly | Occupational health lead | Escalate to chief executive |
| Refusals with a recorded discussion | 100% | Yearly | Occupational health lead | Review the role |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Vaccination record | Occupational health file | Employment plus 40 years |
15. Training
- Occupational health staff are trained in the vaccination schedule and in recording doses.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-POL-003 | Occupational health, safety and wellbeing policy | Policy this procedure supports |
| WRK-SOP-002 | Occupational exposure and needlestick response | Uses the same records |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. The required list set by the ASF Expert Committee against national guidance. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
No e-learning course is linked to this document yet.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)