Breathe Assured Rapid Covid Test

Are you registering for a Fit to Fly / Travel Certificate?

YesNo, I need proof of a day 3 test after arrival in USA, or similar.No, I am using this test for work, event or other purposes - not for travel testing

Do you have a corporate code for this test?*

Yes, this test has been requested via my employerNo, this is a personal test

If you are not using this for travel but have a corporate code provided by your employer, please use our workplace testing form instead. Click to access the correct form.

My corporate coupon is:*

Please contact your employer to issue your code if you do not have it already. If your test is urgent and you can not access your code, please enter your company name instead

YOU ARE REGISTERING FOR A DAY 3-5 TEST POST ARRIVAL IN US

Rules remain a bit unclear about the level of test supervision you need for testing on day 3-5 after arrival in the USA, but many are choosing to have a supervised test with certificate to be safe.

Vaccinated?

For vaccinated people, after arrival in US, day 3-5 tests are advised but not compulsory.

Unvaccinated minors travelling with vaccinated parents can follow the same rules as their vaccinated parents.

Unvaccinated?

Rapid antigen tests on day 3-5 are compulsory for unvaccinated travellers arriving in US, who also need to quarantine for 7 days regardless of test result.

You simply need evidence of having performed a test - full supervision with a certificate is more than sufficient. By entering your passport information too, you have confirmed your ID and can also use your certificate for onward travel if required.

You Are Registering For A Rapid Antigen Test Supervision and Travel Certificate

This test is accepted for entry into many countries including the UK. However, some countries will only accept PCR tests. Please ensure you check your requirements first

Please complete this form carefully to avoid problems with recognition of your certification. We cannot be responsible for any travel problems or other consequences due to inaccurate completion of form.

Country you are planning to enter if test result is negative*

I confirm I have checked that this test is suitable for entry into my stated country if I am using this for Fit to Fly / travel or pre-departure certification

Yes, confirmed

I confirm I am aware this test is not suitable for test-to-release, or after return from red-list countries.*

Yes, confirmed

Airline and / or travel company you are booked with

Airline or travel company you are booked with

Date of planned travel - Fit to Fly or pre-departure test should be within 24-72 hours before travel, depending on country requirements.

Please record your first name and last name below AS SHOWN ON YOUR PASSPORT or your certificate may not be accepted. If your middle name is recorded on your passport please enter that too, otherwise leave blank.

Name - please include ALL NAMES as shown on passport if travelling*

Sex*

Date of Birth*

Date

NHS number if known

Address*

Address Line 1

Address Line 2

Town or CityCounty

PostcodeCountry

Is this the address you are staying at currently, in case you have a positive test and require a PCR test to be posted to you?

YesNo, I am staying at another address

First line of your present address: number, street*

Town or City

Address postcode*

Email. Please enter twice to ensure it is correct.*

Confirmation Email

Preferred Phone Number (ideally mobile)*

Country CodePhone Number

Alternative Phone Number (e.g landline)

Country CodePhone Number

Ethnicity*

Your passport number*

Please ensure you have your passport available at time of consultation for ID verification. You can not be issued with a travel certificate unless passport number is confirmed.

Are you fully vaccinated against Covid-19?

YesNo

What is the coach number, flight number or vessel name you travelled to UK on?

What country were you travelling from when you arrived in UK?

What country did you transit through as part of that journey (if any)?

Unique ID

Please review your answers and confirm they are correct

- especially your email and passport details, if applicable.

Yes, they're all correct!

Please introduce yourself and confirm the clients name and email address for email confirmation of result. If a travel test they also need to confirm their passport number and that they are the person shown on the passport - please ask to see their ID.

Please note - if they have their middle name recorded on their passport, they also need it recorded here so please add it.

Please amend any spelling mistakes in their name, email or other details now.

Client name

First NameMiddle NameLast Name

Client email

please ensure this is the correct email address for their certificate and amend if needed. Please ensure they check spam for their certificate.

This is the date of birth provided - is it correct? Please amend if needed.*

Date

This is the passport number or other appropriate ID, that the client has provided, if applicable. Please check and amend if needed.

This is address provided - please confirm or amend if required*

Address Line 1

Address Line 2

Town or CityCounty

PostcodeCountry

Please check postcode is correct too or amend if needed.*

Have you confirmed that client name, email, date of birth, address and passport number / ID are correct where applicable? They must match any passport details if travelling. If not correct, please amend now.*

Yes, confirmedNot applicable

Please confirm customer's preferred phone number*

Please enter country code, e.g. +44, then the entire number including all zeros, without spaces e.g. +4401234567890

Explain the test will take 15 minutes to get result so you will proceed straight away and then answer questions and have further discussions once test is being processed.

Talk the client through the test and ensure you have seen each client perform a satisfactory swab.

Once the client has added the sample to the cartridge in well S, please make a note of the date and time, as the test will take 15 minutes. Ensure they have marked their test cartidge with their initials if they in are a group.

Test date and time *

Date

24 hour : minutes

Please ensure that flow is occurring, otherwise more fluid may be needed. Sometimes the flow doesn't occur because the sample is too thick or because of air bubbles - a drop more fluid or tapping the cartridge may help.

You should see flow to the end, with appearance of the C (control, not Covid!) line very quickly.

Is test valid?*

Valid test (C line present)Invalid / void test (C line NOT present)

The C line is not present so the result is invalid / void. Please enter any additional information below and the information will be passed to MHRA as per regulations.

As the test is void you can repeat the test for a second time if the customer has another test available. Will you be proceeding with a second test?

YesNo

If the client does not have access to a second test, we can send them a replacement free-of-charge, with a free consultation, if they have time. We may be able to courier a test to them. Alternatively, we will provide a refund and try to help them find an alternative at the airport or elsewhere. Please apologise and explain that it is rare to get an invalid test. Please take their details and inform the customer services team, so they can provide assistance or contact Beth or doctor for advice.

As the test recipient does not want to take a second test, please confirm that you have informed them that the presence or absence of Covid can not be verified.

Confirmed

Is test still invalid after a further 15 minutes? (C line NOT present)

C line is now present. Test is valid.C line is still NOT present - second test is invalid or void.

You have recorded the second test as invalid / void. Please enter any additional information below and the information will be passed to MHRA as per regulations.

As the second test is void, please confirm that you have informed them that the presence or absence of Covid can not be verified. It is difficult to explain why the test is void on two occasions, when we rarely have a void test. It suggests the problem may be with the thickness or otherwise of the sample. However, as a gesture of goodwill, Breathe Assured will offer a refund.

Confirmed

Once the C line is visible you can chat to the client e.g how test works, the limitations of testing i.e the test is not 100% accurate but usually identifies people who have infectious levels of virus.

You can answer any questions and have a general chat - have they had Covid, have they had vaccine? You can explain about our different travel tests that they may want even if they are not currently travelling.

Country they have said they are visiting

Has the client confirmed that this country accepts rapid antigen test for entry?*

YesNo

Airline / travel company they have said they are using - please check and amend if needed

Does individual have any Covid-related symptoms e.g. high temperature, new continuous cough, change to, or loss of, smell or taste?*

YesNo

!!! YOU HAVE RECORDED THAT THE CUSTOMER HAS SYMPTOMS OF COVID OR THAT OTHER MEMBERS OF THEIR GROUP HAVE TESTED POSITIVE. PLEASE CONFIRM THAT THIS IS CORRECT OR AMEND ACCORDINGLY, THANKS !!!

Name of tester / supervisor*

Test requesting organisation*

Requesting organisation type*

Test Result Code*

!!! YOU HAVE RECORDED A POSITIVE OR INCONCLUSIVE TEST. PLEASE CONFIRM THAT THIS IS CORRECT OR AMEND ACCORDINGLY, THANKS !!!

Please confirm that the test result is correctly recorded and that it relates to the correct individual, if they are in a group!*

YesNo

Result = Covid-19 positive. This means test recipient should self-isolate and inform close contacts. Public Health England will be informed of the result to allow track and trace. They should not travel and should remain in quarantine for 10 days. They should obtain a free PCR test from the government as this can identify whether their infection is due to a new variant. Please inform them to simply phone 119 and explain that they have had a positive rapid antigen test and a PCR test has been recommended. This information will also be provided in their automated email.

CONFIRMED that information has been provided and understood.

Result = Covid-19 negative. This means approximately 95% chance that Covid-19 is not present. This adds some reassurance but test recipient should remain cautious about social distancing, mask-wearing and hand-washing / sanitising.

CONFIRMED that information has been provided and understood.

Result = borderline or inconclusive. They have to assume result is positive and therefore they can not be permitted to travel or attend an event. They will not be provided with a certificate, unfortunately. They should be advised to obtain a free PCR test from the government. Please inform them to simply phone 119 and explain that they have had an inconclusive rapid antigen test and a PCR test has been recommended. This information will also be provided in their automated email.

CONFIRMED that information has been provided and understood.

The client has said they have Covid symptoms OR you have recorded a positive test on other memebers of their group. Although their test is negative, this can be the case in around 5 in 100 people with Covid. Unfortunately, therefore, they still need to self-isolate and obtain a PCR test from gov.uk, just in case the rapid antigen test hasn't picked up the virus. This can occasionally happen if it is early in the disease when the viral load may be low. We are not allowed to provide a certificate if they have symptoms or are in the same group as someone with Covid.

Were there any adverse events or other concerns from this test e.g injury to test recipient, evidence of pre-existing damage to testing kit or malfunction of test?*

YesNo

Please provide information below

Unique Specimen ID. This is found in the QR code on the test cartridge if present. Please ask customer to hover phone camera over QR code and read the number that shows up, after the ACONLFDAG letters. Enter it below (partly completed already). If they are unable to read the QR code or the test does not have a QR code on it, please REPLACE the number below with the LOT number of the test (shown on cartridge packet or box).

Type of specimen*

Result date*

Date

Test method used*

Manufacturer of the test equipment*

Once you are happy with all the data, especially that the result and email address are correct, please press SUBMIT and an automatic result notification and certificate will be sent to the client by email.

QR CODE FIELDS

REGISTRATION FOR NURSE SUPERVISED RAPID ANTIGEN LATERAL FLOW COVID TESTING AND CERTIFICATE

Test Supervision and Results