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Request Form for COVID मित्र – A Jain Group Initiative for Employee Welfare
Assistance requisition form for Jain Group's employees affected by COVID-19.
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* Indicates required question
Employee Name
*
Your answer
Employee ID (Please enter your 10 digit alphanumeric characters mentioned in the ID)
*
Your answer
*Note: To know your employee ID (if not available), please contact your campus coordinators.
Employee Mobile Number
*
Your answer
Employee Email ID
*
Your answer
Home Address
*
Your answer
Employee Age
*
Your answer
Gender
*
Female
Male
Prefer not to say
Other:
Institution / Center / School Name
*
Your answer
Institution Location
*
Your answer
Name of the Head of Institution / Center / School
*
Your answer
Symptoms
*
Shortness of breath
Low Oxygen Saturation
Diarrhea
Cough
Nausea
Fever
Other
Required
Covid Test Status (RT-PCR)
*
Choose
Positive
Negative
Test Yet to be Done
Test Results Awaited
Covid Recovered
SRF ID (Provide if applicable)
Your answer
BU Number (Provide if applicable)
Your answer
Mention previous medical condition(s) (surgeries, heart disease, diabetes, blood pressure, allergies, pregnancy, etc.). If not applicable, write No
Your answer
Your current status?
*
At Home
Hospitalized
Type of required support
*
Getting RT-PCR test at concession rate
Isolation bed required
Remarks (If any)
Your answer
Submit
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