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Forms, reference documents and reports

Forms, reference documents and reports for use in the CervicalCheck cervical screening programme.

Forms for GP practices and clinics

Cervical Screening Form (consent form)

Cervical screening form (PDF, 3 pages, 500KB) - this consent form includes an information sheet so that a person can make informed consent

Colposcopy Referral Form

Colposcopy referral form (PDF, 1 page, 308KB) -use this form when making a referral to colposcopy

Hysterectomy

Hysterectomy data collection form (PDF, 1 page, 200KB) - for women who have had total abdominal hysterectomies and do not need future cervical screening

Cervical Screening Not Advised

Cervical screening not advised (PDF, 1 page, 120KB) - for when a person no longer needs to be called for regular cervical screening

Guidance notes

You can find guidance notes for cervical screening sample takers here.

Reference documents

How to complete the cervical screening form (PDF, 1 page, 190KB) - this form is designed to help those working in primary care for GP’s and Practice nurses

How to complete the cervical screening form STI/GUM (PDF, 1 page, 190KB) – this form is designed to help those working in Genito-Urinary Medicine such as sexual health, HIV and sexually transmitted infections clinics

How to complete the cervical screening form Gynae (PDF, 1 page, 190KB) – this form is designed to help those working in secondary care/ gynaecology outpatient clinics who may be performing cervical screening

How to complete the cervical screening form Oncology (PDF, 1 page, 190KB) – this form is designed to help those working in oncology who may be performing cervical screening  

Checklist for cervical screening STI/GUM (PDF, 2 pages, 225KB) – this checklist to help those working in Genito-Urinary Medicine such as sexual health, HIV and sexually transmitted infections clinics when preparing to take a cervical screening test

Cervical screening test

Eligibility framework for cervical screening (PDF, 1 page, 150KB) - reference guide for GPs and sample takers to check if a person is eligible for a screening test

HPV Primary Screening Algorithm (PDF, 1 page, 115KB) - description of referral pathways

Desktop guide - information sheet to support doctors and nurses with HPV cervical screening (You will need login details for National Screening Services Resources website to access this document)

Results recommendation guidance

Cervical screening results and recommendation table (PDF, 1 page, 200KB) - describes the management recommendations provided by the pathology laboratory

Cervical screening results and management recommendations guide (PDF, 10 page, 450KB) - comprehensive guide on the management recommendations of a person based on their results.

Cytology Terminology Table (PDF, 1 page, 220KB) - Recommendations for management of person based on their screening test results

Colposcopy algorithms

Colposcopy Algorithm 1 Management of people with HR-HPV positive & normal or low grade abnormal cytology

Colposcopy Algorithm 2 Management of people with HR-HPV positive and high grade abnormal cytology or any glandular abnormality (including Atypical Glandular Cells)

Colposcopy Algorithm 3 Colposcopy Management of people for Test of Cure following treatment of CIN

Colposcopy Algorithm 4 Colposcopy Management of people for Test of Cure following complete excision of CGIN/SMILE

Colposcopy Algorithm 5 Conservative Management of histologically confirmed CIN 2

CervicalCheck programme reports

 

Multilingual CervicalCheck information videos – for participants and healthcare professionals

CervicalCheck - HPV cervical screening - English

 

Rastreio cervical / HPV cervical screening - Portuguese

 

Badania przesiewowe szyjki / HPV cervical screening - Polish

 

حص عنق الرحم فحص  / HPV cervical screening - Arabic

 

Testul de evaluare cervicală HPV /HPV cervical screening - Romanian

 

La Prueba de Detección del VPH en el Cuello Uterino /HPV cervical screening - Spanish

 

Скрининг шейки матки/ HPV cervical screening - Russian

 

Le frottis cervical de dépistage /HPV cervical screening - French

 

رویکل اسکر سرویکل  / HPV cervical screening - Urdu

 

HPV gimdos kaklelio patikrinimo testą / HPV cervical screening - Lithuanian

 

Dzemdes Kakla Skrīnings / HPV cervical screening - Latvian

 

Cervikálny skríning, na HPV / HPV cervical screening - Slovak

 

Multilingual CervicalCheck information sheets and screening forms - for participants and healthcare professionals

The links below lead to translations of the CervicalCheck Information Sheet and Cervical Screening Form into Arabic, Chinese, French, Irish, Latvian, Lithuanian, Polish, Portuguese, Romanian, Russian, Spanish and Urdu; as well as the English language version.

Is cuid den tSeirbhís Náisiúnta Scagthástála é CervicalCheck
Bosca Oifig Phoist 161, Luimneach
Saorghlao 1800 45 45 55
CervicalCheck is part of the National Cancer Screening Service
PO Box 161 Limerick
Freephone 1800 45 45 55

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Is cuid den Rannóg Sláinte agus Folláine i bhFeidhmeannacht na Seirbhíse Sláinte í an tSeirbhís Náisiúnta Scagthástála. Cuimsíonn sí BreastCheck – An Clár Náisiúnta Scagthástála Cíoch, CervicalCheck – An Clár Náisiúnta Scagthástála Ceirbheacs, BowelScreen – An Clár Náisiúnta Scagthástála Putóige agus Diabetic RetinaScreen – An Clár Náisiúnta Scagthástála Reitiní do Dhiaibéitigh.

The National Screening Service is part of the Health and Wellbeing Division of the Health Service Executive. It encompasses BreastCheck – The National Breast Screening Programme, CervicalCheck – The National Cervical Screening Programme, BowelScreen – The National Bowel Screening Programme and Diabetic RetinaScreen – The National Diabetic Retinal Screening Programme.