Test and Trace

  1. Important Information
  2. Applicant details
  3. About your employment
  4. Benefits details
  5. Bank Account details
  6. Summary

Important Information

Please note that you'll need access to the following information before you can complete this form;

  • National Insurance number
  • NHS Track and Trace reference number
  • Self isolation start date
  • Wage slip (Optional, if applicable)
  • Self assessment form / accounts (Optional, if applicable)
  • Benefits award letter (Optional, if applicable)
  • Bank or Building Society details
  • Proof of Benefits

UPDATE: From 16 August 2021, the Government has removed the legal requirement to self-isolate when contacted by NHS Test and Trace, providing you have received both vaccination jabs and received the second jab at least 14 days before being contacted.

If you're fully-vaccinated, you no longer qualify for a Test and Trace Support Payment, unless you test positive.

To qualify for a statutory TTSP the following must apply:

  • You test positive within 5 days of the onset of symptoms
  • You are employed or self-employed
  • Unable to work from home AND will lose income as a result
  • Currently receiving Universal Credit, Working Tax Credit, income-based Employment and   Support Allowance, income-based Jobseeker’s Allowance, Income Support, Housing Benefit and/or Pension Credit.

To qualify for a discretionary TTSP You should consider whether all the following criteria applies to you before continuing; if any of the following do not apply to you, you will NOT qualify under the discretionary scheme: 

  • You worked 16 hours or more per week for the 4 weeks immediately preceding your requirement to self-isolate
  • You do not have £5,000 or more in capital (if you are part of a couple this amount is between you)
  • You will experience ‘severe financial hardship’ as a direct result of having to self-isolate

This form allows the upload of relevant documentation. Alternatively, you can email it to Testandtracesupport@rugby.gov.uk

Please remember to provide all your supporting evidence within 7 days and quote the unique form reference number shown below in all communication to us and when providing evidence in support of your claim

Test and Trace Support Payment main scheme:

  • Your Test and Trace notice
  • Your most recent full bank/building society account statement
  • Your most recent wage slip
  • Your last self-assessment or audited accounts (if you are self-employed)

Please note that you'll need access to the following information before you can complete this form;

  • National Insurance number
  • NHS Track and Trace reference number
  • Self isolation start date
  • Wage slip (Optional, if applicable)
  • Self assessment form / accounts (Optional, if applicable)
  • Benefits award letter (Optional, if applicable)
  • Bank or Building Society details
  • Proof of Benefits

UPDATE: From 16 August 2021, the Government has removed the legal requirement to self-isolate when contacted by NHS Test and Trace, providing you have received both vaccination jabs and received the second jab at least 14 days before being contacted.

If you're fully-vaccinated, you no longer qualify for a Test and Trace Support Payment, unless you test positive.

To qualify for a statutory TTSP the following must apply:

  • You test positive within 5 days of the onset of symptoms
  • You are employed or self-employed
  • Unable to work from home AND will lose income as a result
  • Currently receiving Universal Credit, Working Tax Credit, income-based Employment and   Support Allowance, income-based Jobseeker’s Allowance, Income Support, Housing Benefit and/or Pension Credit.

To qualify for a discretionary TTSP You should consider whether all the following criteria applies to you before continuing; if any of the following do not apply to you, you will NOT qualify under the discretionary scheme: 

  • You worked 16 hours or more per week for the 4 weeks immediately preceding your requirement to self-isolate
  • You do not have £5,000 or more in capital (if you are part of a couple this amount is between you)
  • You will experience ‘severe financial hardship’ as a direct result of having to self-isolate

This form allows the upload of relevant documentation. Alternatively, you can email it to Testandtracesupport@rugby.gov.uk

Please remember to provide all your supporting evidence within 7 days and quote the unique form reference number shown below in all communication to us and when providing evidence in support of your claim

Test and Trace Support Payment main scheme:

  • Your Test and Trace notice
  • Your most recent full bank/building society account statement
  • Your most recent wage slip
  • Your last self-assessment or audited accounts (if you are self-employed)

Who are you completing this form for? null
What is your name? null
What is your email address? null
What is your contact number? null
Why are you making this application on behalf of someone else? null

A payment will only be made into a bank/building society account in the name of the applicant

A payment will only be made into a bank/building society account in the name of the applicant


 


 

Applicant Details

Applicant Details

Title null
Please state title
First name null
Surname null
Date of Birth null
Please provide your National Insurance number null
null
Change

Your selected address

null
Enter Postcode and select address null
Email address NOTE - A summary of the information provided will be sent to the email address provided along with the outcome of your application null
Contact telephone number null
Have you been contacted by NHS Test and Trace? null

Unfortunately you do not meet the criteria for this scheme as you must have been contacted by NHS Test and Trace service

Unfortunately you do not meet the criteria for this scheme as you must have been contacted by NHS Test and Trace service

Please provide the reference ID provided by NHS Test and Trace null
Please provide the start date of your isolation period null
Please provide the end date of your isolation period null

Any isolation period will need to be in the range of 10 to 14 days from the start date to be eligible. We only accept applications up to 42 days after the first day of self-isolation

Any isolation period will need to be in the range of 10 to 14 days from the start date to be eligible. We only accept applications up to 42 days after the first day of self-isolation

About your employment

About your employment

Are you

Unfortunately you do not meet the criteria for this scheme as you need to be working

Unfortunately you do not meet the criteria for this scheme as you need to be working

Employer Name null
Employer Contact Number null
Employer Address null
Employee Reference Number null
Are you able to work from home during your isolation period?

Unfortunately you do not meet the criteria for this scheme as you are able to work from home.

Unfortunately you do not meet the criteria for this scheme as you are able to work from home.

Will you have a reduction in your earnings?
Upload copy of most recent wage slip

Unfortunately you do not meet the criteria for this scheme as your wages will not be reducing.

Unfortunately you do not meet the criteria for this scheme as your wages will not be reducing.

Are you able to continue your business from home during your isolation period?
What is the nature of your business null
Upload copy of most recent self-assessment/accounts

Unfortunately you do not meet the criteria for this scheme as your income will not be reducing.

Unfortunately you do not meet the criteria for this scheme as your income will not be reducing.

Are you expecting your earnings to reduce because of the requirement for you to self-isolate? null

Unfortunately you do not meet the criteria for this scheme as your income will not be reducing.

Unfortunately you do not meet the criteria for this scheme as your income will not be reducing.

Please explain why you believe that your earnings will reduce due to the requirement for you to self-isolate. Please provide as much detail as possible to support your application null

Benefits details

Benefits details

Please review the benefits below before aswering the questions underneath

  • Universal Credit
  • Working Tax Credit
  • Job Seekers Allowance (Income Based)
  • Income Support
  • Employee Support Allowance (Income Related
  • Housing Benefit
  • Pension Credit

Please review the benefits below before aswering the questions underneath

  • Universal Credit
  • Working Tax Credit
  • Job Seekers Allowance (Income Based)
  • Income Support
  • Employee Support Allowance (Income Related
  • Housing Benefit
  • Pension Credit
Are you receiving any of the benefits listed above? null
Please upload your latest award letter

Unfortunately you do not meet the criteria for this scheme as you are not receiving a qualifying benefit

 You can still be considered for a discretionary payment if you will face financial hardship as a direct result of not being able to work while you are self-isolating. 

Unfortunately you do not meet the criteria for this scheme as you are not receiving a qualifying benefit

 You can still be considered for a discretionary payment if you will face financial hardship as a direct result of not being able to work while you are self-isolating. 

Do you wish to continue and apply for a discretionary payment? null
Have you worked 16 hours or more per week for the 4 weeks immediately preceding your requirement to self-isolate
Have you worked 16 hours or more per week for the 4 weeks immediately preceding your requirement to self-isolate
Do you have £5,000 or more in capital (if you are part of a couple this amount is between you) You will experience ‘severe financial hardship’ as a direct result of having to self-isolate
Do you have £5,000 or more in capital (if you are part of a couple this amount is between you) You will experience ‘severe financial hardship’ as a direct result of having to self-isolate
Will you experience ‘severe financial hardship’ as a direct result of having to self-isolate
Will you experience ‘severe financial hardship’ as a direct result of having to self-isolate
How will this impact on your financial situation? null
Paragraph

Unfortunately you do not meet the criteria for this scheme

Paragraph

Unfortunately you do not meet the criteria for this scheme

Please provide details of the Bank or Building Society Account that you wish the payment to be paid into. Please note this must be in your name

Please provide details of the Bank or Building Society Account that you wish the payment to be paid into. Please note this must be in your name

Name of Bank/Building Society null
Name on the account null
Sort code Enter in the format 11-11-11 null
Account number null
Building Society roll number
Please upload a copy of your most recent statement for this account Accepted file types: jpg, pdf, tiff, doc, docx, gif, png

Declaration

I confirm that the information is true and accurate. I agree to stay at home and self-isolate for the required period. I understand that if I fail to do so, I will be required to pay the funds back and my contact details may be passed onto the police for further action.

Your data will be processed under the terms of Rugby Borough Council privacy notice. You can view this here

 

The Council relies on your consent to access your records contained in NHS Test and Trace Data System known as CTAS for the purposes of confirming your eligibility for this scheme of payment. You can find more information on CTAS via the Privacy Notice (please click here). Your data will not be shared with other entities outside the Council for any purpose and you may withdraw your consent at any time by contacting the Council on 01788 533433. Please be aware that if you do withdraw your consent you will no longer be entitled to the payments under this scheme. For information about how we process the information gathered on the form please click here.

Declaration

I confirm that the information is true and accurate. I agree to stay at home and self-isolate for the required period. I understand that if I fail to do so, I will be required to pay the funds back and my contact details may be passed onto the police for further action.

Your data will be processed under the terms of Rugby Borough Council privacy notice. You can view this here

 

The Council relies on your consent to access your records contained in NHS Test and Trace Data System known as CTAS for the purposes of confirming your eligibility for this scheme of payment. You can find more information on CTAS via the Privacy Notice (please click here). Your data will not be shared with other entities outside the Council for any purpose and you may withdraw your consent at any time by contacting the Council on 01788 533433. Please be aware that if you do withdraw your consent you will no longer be entitled to the payments under this scheme. For information about how we process the information gathered on the form please click here.

Do you agree to this declaration null

You have selected ‘no’ to the above declaration, unfortunately you do not meet the criteria for this scheme.

You have selected ‘no’ to the above declaration, unfortunately you do not meet the criteria for this scheme.

Notification field - Click here to configure