COVID Positive Interview INTRODUCTION AND ROLE Do you have any difficulty hearing, understanding or with your speech? If yes, would you like someone to communicate on your behalf?
Yes
Yes
No
No
Next of Kin/Nominated Spokesperson Details First name:
Last name:
How can we contact them?
PRIVACY STATEMENT To be read exactly:
I need to collect some information from you so that XYZ can help you and stop the spread of COVID-19 in our communities. Your information will be held by us, and we will need to share information with others helping control COVID-19. Your personal information will not be shared publicly. [Are we using the privacy statement law thing - https://arphs.health.nz/public-healthtopics/covid-19/covid-19-privacy-statement]
Do you have any questions or concerns about privacy? No privacy concerns and Privacy Statement emailed/texted Full Privacy Statement read and agreed Person does not agree with Privacy Statement
PERSONAL DETAILS Name:
D.O.B:
Best most direct contact:
Address:
Gender:
We have news that is confirming that you are COVID positive... Its ok, we knew COVID was coming and have been preparing for that. There are 4 things that we want to make sure you are okay with 1. Your Medical Health 2. Your Whare 3. Your Welfare 4. Isolation
Kia Mataara.
Kia Matemateāone Tētahi Ki Tētahi
F
M
YOUR MEDICAL HEALTH Symptoms I’m going to read out a list of symptoms. Please let me know which ones you have at the moment, if any. Tick all that apply: Fever/chills
Runny nose
Headache
Muscle pains
Generally feel weak
Shortness of breath
Irritable/confused
Chest pain
Cough
Diarrohea
Loss of smell/taste
Abdominal pain
Sore throat
Nausea/vomiting
Joint pain
Other
Specify other:
Underlying Issues Tick all that apply: Cardiovascular disease (heart problems, high bloods) Immunodeficiency (weak immune system, asthma, allergies) Diabetes Kidney failure Chronic lung disease Liver disease Cancer Neurological or neuromuscular disease (spine, brain, nervous system or muscle) Other Specify other: What medication do you take?
Do you have any medical worries for your whānau?
Yes
No
If yes, specify:
Do you have a Doctor? Who?
Pregnancy and Post-partum Are you pregnant? If yes, trimester:
Yes
No Yes
Post-partum (less than six weeks since giving birth)
No
History of COVID and Test Results Have you had Covid? If yes, when:
Yes
Have you had a Covid test before? If yes, when:
No Yes
No
Vaccination Have you had a COVID vaccination?
Yes
No
1 dose
2 doses
Pfizer
AstraZeneca
YOUR WHARE Who lives in your whare?
How does your household operate? Who does what? Tamariki? Partner? Mum – Dad? Animals?
Have they been tested?
Yes
No
Can we organise that?
Yes
Can we track them down easily? Where can we find them? How can we contact them? Name
D.O.B
Gender
Number
Address
D.O.B
Gender
Number
Address
Who else are you worried about? Name
No
YOUR WELFARE Occupation Are you working? Primary mahi (includes unemployed, retired, aged care resident, other long-term care resident, child, child at home, stay-at-home parent):
Occupation with 12-years or under Preschool (a child attending or an adult working at a preschool) School (a child attending or an adult working at a preschool) Secondary mahi
Are you an essential worker?
Yes
No
Are you a healthcare worker?
Yes
No
If yes, healthcare worker type
Nurse
Employer name:
Doctor Employer contact:
Are you ok organising to get time off work? Do you need help with this?
Yes
No
Manaaki Tick all that apply: Whānau care plan
Bills
Animal needs
Counselling
Accommodation
Medication
Communication needs
Disability
Is there anything else? Specify:
ISOLATION How do you see isolation working for you and/or your whānau? Refer to poster
Can you stay at home without causing risk to the whānau? Is it better for you to leave or the whānau?
Yes
Yes
No
No
If you are to leave, then we would probably recommend that it’s for a minimum of 7 – 14 days. Do you have some suggestions? Shed, sleepout
We may be able to help turn something livable? Portaloos etc. Yes No We have a marae option if you would like to consider that? Strict spaces have been set up there with every whānau having their own space, medical care and checks are regulated.
Let’s talk about your first actions Was the person already in isolation • Before having COVID symptoms, or • Before the date the positive test was taken Tick all that apply: Close contact with a case Travel-related Alert-level criteria Other, specify:
Let’s talk about getting you sorted Tick all that apply: Isolation at home Isolation at another home Isolation at marae Is your whānau going with you or elsewhere?
Have arrangements been made to move the case to isolate somewhere other than home? If yes, specify:
If you staying home, what do you need to isolate safely from others? Tick all that apply: Portaloo or Portashower Cooking facilities Other, specify:
ISOLATION Let’s talk about getting anyone else sorted Who needs urgent testing?
Let’s track and trace your movements Tick all that apply: Have you been using the Covid tracer app? Using in sign registers? If no, let’s go through your last 14 days of txt messages and Facebook history if that helps Location
When
Timings arrived and left
Who was with you
Notes