COVID-19 Resident Self-Advocacy Form

With the health care system running in many places in full on crisis mode, helping supportive housing tenants navigate the system and convey key pieces of information to busy health care workers will be critical. With this in mind, CSH created a form for supportive housing providers to use if a visit to the emergency room/hospital is necessary from symptoms related to COVID-19. The form has information on the client, the case manager and agency contacts, vulnerable conditions that put them at-risk for complications, and COVID-specific data related to symptoms, testing, and quarantine/isolation status. It can be filled out easily in Word and printed quickly, and can even be compiled by clients themselves. We recommend supplying a partially filled out copy (or more than 1) to clients on your caseloads in case they do need to suddenly seek care. (updated 4/14/20)

Now available in the following languages:

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