20211202_NCTS Daily follow up script for close contacts

For Filing purposes DC ID DC NHI DC Phone #

DC Name DC Address

Disease Contact – Health Check / Follow Up Information This form has been designed to be printed and completed by hand when access to a device / NCTS is not possible, below is some guidance ○ If a circle, tick one □ If a square, it is a checklist, tick all that apply * indicates the question is mandatory Additional notes can be recorded at the end of the document An appendix containing lists longer can be found at the end of the document.

Questionnaire Section 1 – Call Qualification 1. Can you please confirm your first name?

2. Can you please confirm your last name?

3. Can you please confirm your date of birth?

4. What is your preferred language?

See Appendix for list 5. Do you require an interpreter?

Must use approved interpreting service providers 6. Are you aware of any more recent exposures to a case? * 7. Please provide further details on this more recent exposure*

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○ Yes ○ No ○ Yes (proceed to 7) ○ No (proceed to Section 2) ○ Unknown (proceed to Section 2)

Section 2 – Symptoms 8. Do you have any of the following symptoms?* Each one should be asked individually as a Yes/No

9. Do you have any of the following symptoms?* Each one should be asked individually as a Yes/No

□ Fever (feeling hot and cold) □ Shortness of Breath □ Cough □ Sore Throat □ Runny Nose □ Loss of sense of smell □ Headache □ Muscle pain □ General weakness □ Chest pain □ Abdominal pain □ Joint pain □ Nausea (vomiting) □ Diarrhoea □ Irritability/ confusion □ Other

10. Please specify any ‘Other’ symptoms

11. Please specify any further details relating to this individual’s symptoms?

12. Have you advised the contact to get an immediate test based upon their symptoms? * 13. Have you checked your temperature in the last 24 hours?

○ Yes ○ No

○ Not Taken ○ Below 38 Degrees ○ 38 Degrees or above 14. How did you take your temperature? ○ Orally ○ Per Axilla (armpit) ○ Other Section 3 – Only ask if Swab Due Today / Tomorrow 15. I have reminded the contact to get a test ○ Yes today? ○ No 16. Comments on why Test Result is not received yet

Section 4 – Household 17. What is your living situation, do you live alone or with others?

18. Does anyone in your household feel unwell? * 19. Are all people who are feeling unwell already being managed as a case or contact? * 20. Select the relevant symptoms*

○ Lives alone (proceed to 22) ○ Lives with others (proceed to 18) ○ Yes (proceed to 19) ○ No (proceed to 22) ○ Yes (proceed to 22) ○ No (proceed to 20) □ Fever (feeling hot and cold) □ Shortness of Breath □ Cough □ Sore Throat □ Runny Nose □ Loss of sense of smell □ Other

21. What action is required as a result of the household members symptoms (if any)

22. Please note any other relevant information about the living situation

23. Is your living situation still suitable for you to quarantine / stay home?

Section 5 – Compliance 24. Have you left the place you are staying in the last 24 hours?

○ Yes ○ No ○ Yes - compliant ○ Yes - non-compliant ○ No ○ Not Answered

25. Please specify further details regarding whether you have left your property.

26. Have any people visited the place you are staying?

27. Please specify further details regarding whether you have had visitors.

○ Yes - compliant ○ Yes - non-compliant ○ No ○ Not Answered

Section 6 – Welfare and Assistance 28. Do you require any assistance or support?

29. What assistance or support do you require?

30. Do you or does anyone in your household feeling anxious or stressed?

31. Is there anyone else that you have been supporting who is or will be affected by your self-quarantine?

32. Details about impact on supported people

33. Is there anything else concerning you or anything else you need?

Section 7 – Final 34. Please provide any other relevant information to today’s check-in completion:

○ Yes (proceed to 29) ○ No (proceed to 30) ○ Not answered (proceed to 30) □ Food □ Accommodation □ Financial Support □ Prescriptions □ Animal Needs □ Medical Needs □ Disability Needs □ Other ○ Yes ○ No ○ Not answered ○ Yes (proceed to 32) ○ No (proceed to 33) ○ Not answered (proceed to 33)

Additional Notes Related Note Question

Appendix Language List Afrikaans Arabic Cantonese Cook Islands Maori Dutch English French German Gujarati Hindi Italian Japanese Korean Mandarin Maori New Zealand Sign language Northern Chinese Punjabi Russian Samoan Sinitic Spanish Tagalog Tamil Thai Tongan Vietnamese Yue Other