Request Form for COVID मित्र – A Jain Group Initiative for Employee Welfare
Assistance requisition form for Jain Group's employees affected by COVID-19.
Employee Name *
Employee ID (Please enter your 10 digit alphanumeric characters mentioned in the ID) *
*Note: To know your employee ID (if not available), please contact your campus coordinators.
Employee Mobile Number *
Employee Email ID *
Home Address *
Employee Age *
Gender *
Institution / Center / School Name *
Institution Location *
Name of the Head of Institution / Center / School *
Symptoms *
Required
Covid Test Status (RT-PCR) *
SRF ID (Provide if applicable)
BU Number (Provide if applicable)
Mention previous medical condition(s) (surgeries, heart disease, diabetes, blood pressure, allergies, pregnancy, etc.). If not applicable, write No
Your current status? *
Type of required support *
Remarks (If any)
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy