Title Please select --> Mr Mrs Ms Miss Mstr Mx
First name
Last name
Date of birth (dd/mm/yyyy)
Please enter the first line of your address or your postcode Search
Phone
Does the telephone number accept calls from unknown numbers? Please select --> Yes No Don't know
Email
How many other people live in the household? None One Two Three Four Five Six
Do you have access to the internet e.g. online shopping? Please select --> Yes No
Have you received information to advise that you are on the shielded list and were advised to self-isolate? Please select --> Yes No
Have you registered yourself on the GOV.UK website to let them know whether or not you need support? Please select --> Yes No
While we can provide support in the meantime, you must register on the gov.uk website to ensure central government are aware of your needs.
Are you self-isolating due to any of the following? (select as many as necessary) A member of the household displaying symptoms You are displaying symptoms You have been contacted by the Track & Trace Team and been advised to self-isolate for 10 days due to contact with someone who has tested positive for COVID-19
If you are displaying symptoms of COVID-19, have you had a test? Please select --> Yes No
On what date was the test carried out? (dd/mm/yyyy)
Have you received your test results? Please select --> Yes No
Have you tested positive or negative for COVID-19? Please select --> Positive Negative
Do you have a test booked? Please select --> Yes No
On what date is the test to be carried out? (dd/mm/yyyy)
You need to get the test done in the first 5 days of having symptoms. You can book a test at Chapel Lane, Wigan, book a test at another test centre or you can call 119 if you have problems using the internet.
Do you feel safe to self-isolate in your own home? Please select --> Yes No
Do you have family, friends or neighbours who can help with shopping, prescriptions or any other basic needs? Please select --> Yes No
How much support is needed? Please select --> One-off support Ongoing support
What kind of support do you require? (select as many as necessary)
Food / household items delivery
Are you able to pay for the items you require? Please select --> Yes No
Please take a look at our database of local businesses offering deliveries of food and essentials for residents.
Do you need help taking this delivery inside your home? Please select --> Yes No
Prescription collection
Do you pay for your prescriptions? Please select --> Yes No
Someone to talk to
Financial support / advice
Digital support
Please describe the issues you need help with (select as many as necessary) Connecting with family and friends Setting up an email address Shopping online Banking online Other
Please provide details of the additional digital support needed 0 of 250 characters
Please choose the device you are using Please select --> Android phone or tablet iPhone or iPad Windows PC or laptop Other
Please state the type of device below 0 of 250 characters
Practical support
Please describe the issues you need help with (select as many as necessary) Dog walking Gardening Post office / bank runs General errands Personal care Home maintenance / DIY
Wellbeing support
Please describe the issues you need help with (select as many as necessary) Advice and guidance Mental health and wellbeing Physical activity session
Book a COVID-19 test
Please provide any further information that we may need to be aware of 0 of 500 characters
All information submitted via this request will be managed in accordance with our Emergency Planning and Service Delivery Privacy Notice
I am happy for my contact details and information provided above to be shared with volunteers / community groups / organisations who are working with us to provide the support needed Please select --> Yes No
I am happy for my details to be checked against the National Shielded list to ensure I am receiving the correct support Please select --> Yes No
© Wigan Council
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