Covid 2019 Social Impact – Assessment Form

Section 1: Personal data
   Do you have a driver's license?
Section 2: Financial / Employment data
What is your primary source of income?
Senior citizen related
   Senior Citizen receiving pension income
   Senior Citizen without pension income
Odd job related (a casual or isolated piece of work, especially one of a routine domestic or manual nature)
   Do you have an odd job?
   Do you own a business?
Covid 2019 Effects
How has the Covid 2019 affected you
   My Employer has terminated the labor agreement
   My Employer has reduced my salary and working hours
   My Employer has sent me on vacation with pay
   My business has closed , or has reduced in income
   I have been evicted from apartment /house
   I no longer have medical insurance
   I am a senior citizen (62+)
Section 3: Basic Needs Assessment
Please let us know which needs you have based on the impact of COVID 2019
   Financial Assistance
   Medical Insurance / Medical Aid
   Legal Aid for an unresolved labor dispute due to Covid 2019
   Food and personal hygiene products
Special Circumstances
   I have a disability
   I have minor children in my care
   I am a Senior Citizen with limited mobility
   I have an underlying medical issue