JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Contact information
If You are a COVID-19 Positive or Do you have any COVID-19 Symptoms, register here
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Nation-wide Distribution of Kaba Sura Kudineer for COVID-19 positive Patients
Initiative by Central Council for Research in Siddha, Ministry of AYUSH, Govt. of India, Arumbakkam, Chennai 600106
CCRS
Consent for participation- mandatory
I hereby give my consent to take the Ayush intervention (Kaba Sura Kudineer) as per the dosage prescribed to me based on my health status. I also give my consent to provide the requisite information as and when asked by me through telephonic interview. I understand that my confidentiality will be maintained and the information provided by me will only be used for research purpose for the benefit of public.
Kindly read the above-quoted Consent. if You agree, Kindly submit the form. We will contact you soon...
Name
*
Your answer
Email
Your answer
Age
*
Your answer
Gender
*
Male
Female
Transgender
Address
*
Your answer
Your city or Nearest City
*
if you choose appropriate city, the officials from below quoted city will contact you soon
Chennai
Puducherry
Thiruvananthapuram
Palayamkottai/Tirunelveli
Bengaluru
New Delhi
Tirupati
Other:
Phone number
*
Enter the mobile number with out country code (+91 or 0)
Your answer
Aadhaar number/Voter ID /any Govt. ID card with photo
*
Your answer
Have you taken RT-PCR test
*
Choose
Yes
No
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report