Oregon Health Authority

Oregon Health Authority

Request for COVID-19 Wraparound Assistance from Columbia Gorge Health Council/ Bridges to Health
SERVICES:
- For people who need assistance with purchasing food, meds or cleaning supplies to be able to isolate themselves safely and remain in their home
- If emergency housing is needed, you need to call your Health Department to arrange that FIRST
- NON- URGENT SUPPORT:
  - If you have lost wages during your isolation period you will need to show proof in order to get support for assistance with rent or utilities.
  - Rent and utility is not guaranteed and will be addressed if our capacity allows, as isolation period comes to an end.
Instructions:
- The CBO and the person requesting services should complete Sections 1 and 2.
- If the person requesting services is a COVID-19 close contact (has been within six feet of a COVID-19 case for 15 minutes or longer during the period of time that person may have been contagious COVID-19), fill out Section 3. Skip section 4.
- If the person requesting services is a COVID-19 case, skip Section 3 and fill out Section 4.
Section 1. Community Based Organization (CBO) information
Referred by: (agency, if not self):
Referring agency staff person and contact info (if not self):
Section 2. Person requesting services information
Name (first, middle, last):
Date of birth:

MonthDayYear
Date
Phone number:
Address:
Date of services:

MonthDayYear
Date
How many people are in your household?
Date I was within six feet of a COVID 19 case for a total of 15 minutes or more:

MonthDayYear
Date
Known COVID-19 case information: Please complete as much information as you are able about the person who is known to have exposed you to COVID-19.
Known case Name (first, middle, last):
Known case Date of birth:

MonthDayYear
Date
Known case Phone number:
known case Address:
known case County of Residence:
Confirm and attest that the information above is true and correct with your initials initial below:
Section 4. Attestation - COVID-19 case

A COVID-19 case is someone who received positive test result OR has two or more COVID-19 symptoms within the last 10 days and was a close contact of a confirmed COVID-19 positive case. Please complete this section if you believe you are a COVID-19 positive or presumptive positive case. You may be asked to verify your testing information with your results.
Confirmed positive- testing information:
Date I received a positive COVID 19 test:

MonthDayYear
Date
Presumptive positive - symptom and exposure information:
Date I began having two or more of the following symptoms: shortness of breath, cough, fever, new loss of smell or taste (if no symptoms, write N/A):

MonthDayYear
Date
AND
Date I was within six feet of a COVID 19 case for a total of 15 minutes or more:

MonthDayYear
Date
Confirm and attest that the information above is true and correct with your initials below:
PERSON REQUESTING SERVICES:

I agree to let the Community Based Organization (CBO) and staff person listed above see and use my personal information to help me receive short-term wraparound supports during my COVID-19 isolation and quarantine period. agree to let the CBO listed above share my information with the Local Public Health Authority (LPHA) if needed. The CBO and LPHA are required to protect and keep any signed information private.
I am not receiving wraparound services for isolation or quarantine from another organization.
Signature

Clear
Date

MonthDayYear
Date
FOR CBO Administrative Use ONLY: This person has met criteria to receive wraparound services (check at least one):
Close contact: This person has been within six feet of a known case for a total of 15 minutes during the time they would have been in isolation.Confirmed Case: This person has provided a positive test resultPresumptive case: This person has been within six feet of a known case for a total of 15 minutes during the period they would have been in isolation AND has two or more symptoms of COVID-19.
CBO approval (name)
CBO approval (date):

MonthDayYear
Date
Start date for services:

MonthDayYear
Date
Estimated end date for services:

MonthDayYear
Date
Document accessibility: For individuals with disabilities or individuals who speak a language other than English, OHA can provide information in alternate formats such as translations, large print, or braille. Contact Mavel Morales at 1-844-882-7889, 711 TTY or OHA.ADAModifications@dhsoha.state.or.us.
CBO denial and date:
Should be Empty: