1Page 1 2Page 2 3Page 3 4Page 4 5Page 5 6Page 6 7Page 7 8Summary Progress Page 1 Completing application on behalf of someone This grant scheme has now closed. Please do not continue with the form, as you will not be able to submit it. Who are you completing this form for? Myself Someone else This grant scheme has now closed. Please do not continue with the form, as you will not be able to submit it. Your name Relationship Family member Third party agency LCC advisor Other If other, please specify Contact email address Contact telephone number Reason for Application Have you tested positive for Covid-19? Yes No Have you received a notification from NHS Test and Trace because you have been in contact with someone who has been identified as a suspected or confirmed case of the Omicron variant – between the period 30 November 2021 to 13 December 2021? Select No if you received notification on or after 14 December 2021. Yes No You will need to provide a copy of your email or text notification from NHS Test and Trace. Have you received a notification from NHS Test and Trace because you have been in contact with someone who has tested positive for Covid-19? Yes No You are exempt from having to self-isolate if any of the following criteria apply to you: you are fully vaccinated you are below the age of 18 years and 6 months you have taken part in or are currently part of an approved COVID-19 vaccine trial you are not able to get vaccinated for medical reasons Are you exempt from having to self-isolate? Yes No Are you applying as a parent or guardian of a child or young person who is required to self-isolate? Yes No Sorry, you do not qualify for this payment. Parent or Guardian Application questions Do you need to take time off work to care for them while they self-isolate? This is limited to one parent or guardian per household for the child or young person’s self-isolation period. Yes No Are you employed or self-employed? Yes No Are you able to work from home while undertaking caring responsibilities? Yes No Will you lose income as a result of not being able to work from home while undertaking caring responsibilities? Yes No Sorry, you are not entitled to a Test & Trace Support Payment Scenarios Please read the below scenarios. You will be asked to choose which scenario applies to you: A. You are the parent or guardian of a child or young person in your household who has been told to self-isolate by NHS Test and Trace due to testing positive for COVID-19B. You are you the parent or guardian of a child or young person in your household who has been told to self-isolate by NHS Test and Trace due to being a close contact of someone who has been identified as a suspected or confirmed case of the Omicron variant – between the period 30 November 2021 and 13 December 2021.C. You are the parent or guardian of a child or young person in your household who is aged 25 or under with an Education, Health and Care (EHC) Plan and been told to stay at home and self- isolate by NHS Test and Trace because they have tested positive for COVID-19D. You are the parent or guardian of a child or young person in your household who is aged 25 and under, is not exempt from self-isolation, has an Education, Health and Care (EHC) Plan and been told to stay at home and self- isolate by NHS Test and Trace because they have been notified as a close contact of someone with COVID-19 (by NHS Test and Trace or the NHS COVID-19 app).E. You are the parent or guardian of a child or young person in your household who is aged 25 and under, has an EHC Plan, and has been told to stay at home and self-isolate by NHS Test and Trace because they are a close contact of someone who has been identified as a suspected or confirmed case of the Omicron variant of COVID-19 – between the period 30 November 2021 and 13 December 2021.F. You are the parent or guardian of a child or young person in your household who has been told to self-isolate by a local health care team due to an outbreak in their education or care setting. Select which scenario applies to you Scenario A Scenario B Scenario C Scenario D Scenario E Scenario F You will need to provide a copy of the email or text notification from NHS Test and Trace and your NHS Test and Trace ID due to also being a close contact. You will need to provide a copy of the email or text notification from NHS Test and Trace. You will need to provide a copy of the email or text notification from NHS Test and Trace and parent/guardian T&T ID; EHC plan – you will need to provide details of the education and care setting so EHC plan can be verified You will need to provide a copy of the email or text notification from NHS Test and Trace; EHC plan – you will need to provide details of the education and care setting so EHC plan can be verified You will need to provide a copy of the email or text notification from NHS Test and Trace; EHC plan – you will need to provide details of the education and care setting so EHC plan can be verified You should receive notification from NHS Test and Trace and have an 8 digit reference Enter their 8 digit Test and Trace reference Upload a copy of the NHS Test and Trace notification they received Enter your 8 digit Test and Trace reference Upload a copy of the NHS Test and Trace notification you received No information is required, please proceed to the next page. Page 2 Personal details of the child/young person who has been told to self-isolate Your relationship to the child First name Middle name (optional) Last name Date of birth Home address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Place of education or care setting Child’s year group Contact name, email, and phone number for Place of education or care setting Your child’s first day of self-isolation Does your child have an Education, Health and Care Plan? This is to support applications from parents and guardians of young people between 16 and 25 who have additional support needs Yes No Self-Isolation Details Enter the date you (or your child) have been told to isolate from by NHS Test and Trace Enter the date your (or your child's) self-isolation will end Enter your 8 digit Test and Trace reference Upload a copy of the NHS Test and Trace notification you received This can be a photo of the letter or email, but it must clearly show the date you received the notification and NHS Test and Trace ID. Consent I consent to Liverpool City Council verifying that I have been contacted by NHS Test & Trace and told to self-isolate from the date provided above. During your period of self-isolation were you required to quarantine or self-isolate having returned to the UK from another country? Yes No What date did you return to the UK? Which Country did you return from? No information is required, please proceed to the next page. Page 3 Your Personal details First name Middle name (optional) Last name Date of birth Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Email Contact number National Insurance number No information is required, please proceed to the next page. Page 4 Your Employment status Are you If you are both employed and self-employed, select the option where you will lose most income. Employed Self-employed Not working Do you receive statutory sick pay? Yes No Do you receive full pay whilst you self-isolate? Yes No Have you been furloughed? Yes No Job role If you have more than one job, enter the role where you will lose most income. Are you able to work from home whilst you self-isolate? Yes No Employer name Employer address Employer contact number Payroll reference Are you able to work from home or elsewhere whilst you self-isolate? Yes No Nature of business Name of business/limited company Upload proof of self-employed status This can be a copy or photo of your most recent accounts, self-assessment return or business bank account statement no more than 2 months old. No information is required, please proceed to the next page. Page 5 Benefit details Do you receive any of the following benefits? Tick all that apply. Universal Credit Working Tax Credit Income-based Employment Support Allowance Income-based Job Seekers Allowance Income Support Housing Benefit Pension Credit I don't receive any benefits Discretionary Scheme Questions Can you confirm you are on a low income and will face financial hardship as a result of not being able to work while you are self-isolating? Yes No Do you have any fixed costs for example rent/mortgage or other fixed costs that must be paid during the period of your self-isolation? Yes No Please provide details of rent, mortgage or other fixed costs, and state the amount What income will you receive each week during your period of self-isolation? Do you have a partner? Yes No What income will your partner receive each week during the period of self-isolation? Please confirm the number of any dependent children in your household Do you or your partner have any savings? Yes No Please state amount No information is required, please proceed to the next page. Page 6 Bank details Name of bank or building society Account holder's name Account number Sort code Upload a copy of a recent bank statement This must be no more than 2 months old and can be a photo of the bank statement showing the account holder’s name, account number and sort code. If you are entitled to a payment, we will pay it into this bank account. If you are employed it should also include proof of wages being paid in. No information is required, please proceed to the next page. Page 7 Declaration By submitting this form: I confirm that the information I have provided is true and accurate. I confirm I have received a notification from NHS Test and Trace and have either tested positive for Covid-19 or been in contact with someone who has tested positive and have been advised to self-isolate, or I am the parent or guardian of a child or young person in the same household and need to take time off work to care for them while they self-isolate I have read the government guidance for the self-isolation payment scheme and confirm I meet the criteria. I am employed and not able to work from home and will lose income as a result OR I am self-employed, my business cannot be carried out while self-isolating and I will lose income as a result of this. You must agree to the declaration in order to submit your application. No information is required, please proceed to the next page. Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page Loading form summary...