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Rarotongan
Samoan
Tongan
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COVID-19 Support
COVID-19 Self-isolation Form
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COVID-19 Self-Isolation Form
First Name
*
Last Name
*
Date of birth
Self-isolation address
Phone
*
Ethnicity
Samoan
Tongan
Fijian
Cook Island
Niuean
Solomon Islands
Kiribati
Tokelauan
Tuvaluan
Maori
European
Other (please specify)
If you selected other please specify:
Email Address
*
Are you or your family self-isolating at the request of the Waikato District Health Board or Ministry of Health?
Yes
No
If you answered no to the above question please briefly explain:
How many people are self-isolating in the home?
How many of those self-isolating in the home are children under the age of 18?
How many in the home have tested positive for Covid-19? (All Variants)
When did you begin your self-isolation?
When did you do your last Covid-19 Test?
What was the result of your last COVID-19 test?
Negative
Positive
Still waiting for results
Is anyone in your home physically, emotionally or mentally unwell? Or requires any special needs assistance?
Yes
No
If you answered yes to the above question please briefly explain:
Do you have any family or friends that live locally that can cater to your needs (Contactless)?
Yes
No
If you answered yes what is their name and contact details?
Are you currently receiving support from any other Community or Government organisation?
Yes
No
What urgent assistance do you require (Covid RAT Test, food, medical supplies etc)?
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