COVID-19 Report and Support Form

The Report and Support form helps identify people who are at higher risk for severe illness and hospitalization from COVID-19, within the first 5-7 days of developing symptoms. The form is used to determine whether a person is eligible for and would benefit from COVID-19 medications. Those who meet initial criteria will receive a phone call from a member of Nova Scotia Health's COVID-19 Treatment Team for further assessment.

As COVID-19 medications do not benefit everyone, you will only receive a phone call if you are eligible.

This information is collected responsibly and confidentially to improve COVID-19 recovery rates and provide better access to medicine.

People who identify as Black or African Nova Scotian and First Nations are among those at higher risk for severe outcomes from COVID-19. Anti-Black racism, systemic racism, higher rates of chronic disease and too few culturally specific health care services compound this risk. We ask people from these communities to voluntarily self-identify so people can be considered for medication based on all relevant personal risk factors.

This form is recommended to be completed if you have booked a PCR test or had a positive rapid test. If you complete the form before PCR testing and test negative, your information will be deleted.

Please complete the form as accurately as possible.

The personal health information you voluntarily provide on this form is protected under the Personal Health Information Act (PHIA). The submitted information received through this form is subject to Nova Scotia Health Authority security and privacy policies.

The collected personal health information will only be used to determine if someone is eligible for and would benefit from COVID-19 medication, unless otherwise authorized by law or your express consent. Information collected will be reviewed and assessed by the Nova Scotia Health COVID-19 Treatment Team, after which the original collection be deleted in 10 days.

Any secondary use or disclosure without express consent is limited to use for quality and risk management purposes or to aggregate de-identified information.