COVID-19 Case Form

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Tested positive for COVID-19 and Isolating at home?
Awaiting COVID-19 test results?

We are here for you!

The coronavirus pandemic has everyone feeling anxious, but CSO Cape Town is here to assure you that we will monitor any suspected or confirmed cases of COVID-19 in our community to keep those individuals, and their families, safe.

Please use the form below to sign up for the COVID-19 Wellness Monitoring Programme.

If you do not wish to join the COVID-19 Wellness Monitoring Programme but you have tested positive, please continue to complete the form so that we can monitor the impact of COVID-19 on our community. You can remain anonymous if you would prefer to. This form does not replace any Government processes, but rather is in addition to these protocols.

Would you like to join the COVID-19 Wellness Monitoring Programme? *
YesNo
First Name
Surname
I wish to remain anonymous
Yes
Age *
If you are younger than 18 years old, please enter your parent/ guardian contact details below:
Parent/Guardian Name
Parent/Guardian Cell Number
Phone Number (if you would like us to check-in with you telephonically)
Suburb *
Town/City *
Address
Number of people living with you *
What date did you test positive for COVID-19?
Did anyone from CSO Medical treat you? *
YesNo
Please provide further details (e.g. CSO Medic’s name or date)
Have you made a full recovery? *
YesNoI am recovering well at home
Which Shul do you belong to? *
Have you attended Shul or a Charity Organization in the last 7 days? *
YesNo
Please specify which one?
Other comments

Verification

Please enter any two digits *Example: 12
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Please note this data will be secured, access restricted and kept strictly confidential. The information gathered will be solely used for the purpose of tracking COVID-19 community cases in the Western Cape and to assist CSO Cape Town with the in-house COVID-19 Wellness Monitoring Programme.

Access to the data will be restricted to key personnel only.

If you would like your submission to be deleted, kindly call us on 087 820 4949 to request the deletion.

IF YOUR SYMPTOMS WORSEN, PLEASE CALL US IMMEDIATELY

FOR ANY SECURITY OR MEDICAL EMERGENCY, SUSPICIOUS ACTIVITY OR POTENTIAL THREATS SPECIFICALLY RELATED TO THE JEWISH COMMUNITY OR JEWISH INSTALLATIONS, CONTACT CSO CAPE TOWN ON

086 18 911 18

For general enquiries please call 087 820 4949

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