Covid 2019 Social Impact – Assessment Form

Section 1: Personal data

Lastname

Firstname

Date of birth

Phone number

Mobile number

Address

Location/ District

Medical Conditions

Other Medical Conditions

Gender

ID Number

Legal Status

Marital Status

House Number

Do you have a driver's license?

Driver's License type

Other phone number

Section 2: Financial / Employment data

What is your primary source of income?

Are you employed?

Employer

Position

Monthly Salary in FLS

Contract Status

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?

Description

Do you own a business?

Average income per month generated in FLS

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

Type of disability

I have minor children in my care

How many minor children

I am a Senior Citizen with limited mobility

I have an underlying medical issue