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Side effects of prophylactic medications taken by healthcare workers for COVID-19
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* Indicates required question
Name the institution/hospital you are a part of?
*
Government Hospital, Karaikal
Vinayaka Missions Medical College and Hospital, Karaikal
Others
If any other, specify the name of the hospital/institution
Your answer
Name of the participant
*
Your answer
Age (in years)
*
Your answer
Sex
*
Male
Female
Other
Email address
*
Your answer
Mobile number
*
Your answer
Name of the Department you work
*
Your answer
Your designation
*
Your answer
Date of starting the prophylaxis
*
MM
/
DD
/
YYYY
Date of filling this form
*
MM
/
DD
/
YYYY
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