COVID-19 Case Form

Tested positive for COVID-19 and Isolating at home?

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 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. All information given to CSO Cape Town is strictly confidential and will only be used by CSO Medical Staff and the attending physician of the patient. 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
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 *
Suburb *
Town/City *
Residential Address *
Current Address (if you are isolating somewhere that is not your residential address)
Number of people living with you *
What date did you test positive for COVID-19?
Did anyone from CSO Medical treat you in the past 7 days? *
YesNo
Please provide further details (e.g. CSO Medic’s name or date)
Which Shul do you belong to? *
Have you attended Shul, School, or a Charity Organization in the last 7 days? *
YesNo
Please specify which one?
Other comments
*
By completing this form, I am giving permission to CSO Cape Town to contact me on a regular basis during my isolation period. I agree to co-operate with the assigned volunteer and will provide said volunteer with any medical information that they require.

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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.

24 HOUR EMERGENCY: 086 18 911 18

Tested positive for COVID-19 and Isolating at home?

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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