COVID-19

First Name *

Last Name *

Date of birth

Self-isolation address

Phone *

Ethnicity

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?

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?

Is anyone in your home physically, emotionally or mentally unwell? Or requires any special needs assistance?

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)?

If you answered yes what is their name and contact details?

Are you currently receiving support from any other Community or Government organisation?

What urgent assistance do you require (Covid RAT Test, food, medical supplies etc)?

ReCaptcha *

COVID-19 Self-Isolation Form