Vulnerable People - Help Request
Your Details
 First name
 Surname
 Address
 Postcode
 Email
 Telephone
 Your age
 What do you require help with? (e.g. shopping, medicine, care)
 Reference Number
This will be provided once you have completed the form
Vulnerable Groups
Please indicate on behalf of the person or household requiring help which of the following are applicable:
 Have you received a letter or text message from the Government/GP/Consultant to say you are classed as an Extremely Vulnerable Person and need to shield at home?

 Do you qualify for support from Social Services?

 Are you pregnant?

 Are you aged over 70 and social isolating due to Government advice?

 Are you aged under 70 with one of the following underlying medical conditions?

  • chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
  • chronic heart disease, such as heart failure
  • chronic kidney disease
  • chronic liver disease, such as hepatitis
  • chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
  • diabetes
  • problems with your spleen – for example, sickle cell disease or if you have had your spleen removed
  • a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy
  • a body mass index (BMI) of 40 or above
 Please indicate which of the following categories you fall into?








 Are you or a member of the household socially isolating due to covid 19 symptoms?

 Have you been asked to self isolate due to coming into close contact with a person who has been confirmed as having Covid 19?

 Do you or the household requiring help not fall into any of the vulnerable group categories list previously on this form?

Data Protection
We will use the information to provide and coordinate humanitarian support in response to the COVID-19 pandemic. The basis under which the Council uses personal data for this purpose is that is necessary for the performance of a task carried out in the public interest.
The Data Controller is Gedling Borough Council, Civic Centre, Arnot Hill Park, Arnold, Nottingham, NG5 6LU. You can contact the data protection officer at the above address or by email at dataprotectionofficer@gedling.gov.uk
Further information including how long we retain your data, who we share with and your rights can be found in our privacy notice.