Suspected/Confirmed Covid-19 Case

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Verification

Please tell us the address that relates to your request.

Address

Use this form to record a suspected/confirmed Covid-19 case

Please state why you are completing this form

Which care home are you associated with?

Are you completing this form about you or on behalf of someone else?

Doncaster council employee details

Doncaster Council worker name

Representative contact details

Please ensure you do not use any special characters in your details except the @ in your email address.

Title

First name

Last name

Mobile number

Landline number

Please select your prefered telephone contact method?

We will need to gather some more information about this case of Covid-19, shall we contact the patient or you as the representative?

Suspected/Confirmed Covid-19 case details

Please ensure you do not use any special characters in your details except the @ in your email address.

Title

First name

Last name

Gender

Date of birth

NHS number (if you know it)

Mobile number

Landline telephone number

Please select your prefered telephone contact method?

Someone from our team will call you within 24 hours of completing this form

When is the best time for you to be available?

9.00am to 12.30pm

1.00pm to 7.00pm

Specific time – please specify (hh:mm)

We will try to contact you at the time you have specified where we can

Details of symptoms of Covid-19

When did you or the person you are completing this form on behalf of first begin to notice symptoms of Covid-19?

Have you or has the person you are completing the form about had a test for Covid-19?

What was the result of the test?

Date of test

Have you or has the person you are completing the form about had any physical contact or been within a 2m distance of anyone else change to 2 days (or 3 days if care home resident) prior to symptoms starting up until today?

Someone from our team will call within the next 24 hours, in preparation for that call please begin to create a list of people that you or the person that you are filling this form out on behalf of have come into contact with within the 3 days prior to symptoms starting up until today.