AIIMS Patna COVID-19 Positivity Reporting Portal and Helpline for Healthcare Workers  
We appreciate our healthcare workers for tirelessly risking their lives while caring for patients during this COVID-19 Pandemic. Your physical and mental health is of utmost importance to us. Please fill this form for reporting your positivity status to MS Office and to reach COVID-19 Helpline for Healthcare Workers. Our team of doctors will get back to you at the earliest.
Sign in to Google to save your progress. Learn more
Email *
Phone number (WhatsApp number preferable) *
Please enter your 10 digit mobile number e.g. 97******89
Name *
Employee/Enrolment/Biometric ID *
EHS No. or CR No. *
Age (in completed years) *
Gender *
Designation *
Department *
Do you have any of the following co-morbidities or risk factors? *
Yes
No
Diabetes Mellitus
Hypertension
Hypothyroidism
Chronic Kidney Disease
Chronic Lung Disease (COPD)
Bronchial Asthma
Angina/Myocardial Infarction
Brain Stroke
Cancer
Pregnancy
If you have any other chronic illness or history of any major surgery in past, please mention it here
No. of doses of COVID-19 vaccine received *
If Vaccination Received- Date of 1st Dose
MM
/
DD
/
YYYY
If Vaccination Received- Date of 2nd Dose
MM
/
DD
/
YYYY
Date of onset of COVID-19 related symptoms *
MM
/
DD
/
YYYY
What was the date of the COVID-19 positive test? *
MM
/
DD
/
YYYY
Area of work at the time of COVID-19 positive test *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy