Submit Covid Information

Name of Employee^*

Age of Employee^*

Designation^*

Department^*

Nature of Job^*

Regular Temporary

PF Number / Employee Code

[Mandatory for regular employee]

Mobile No.^*

Residential Address^*

Category^*

Self Relative In Contact

Lab Details of the Employee:
Name of the Lab^*
Lab Phone Number^*
Date of onset of first symptom^*	[dd/mm/yyyy]
Date of Test^*	[dd/mm/yyyy]
Date of Report^*	[dd/mm/yyyy]

Relative/ Lab Details [Who is tested +ve]:
Relative / Contact person Name^*
Relative Age^*
Relative Mobile No.^*
Relation with Covid patient^*
Whether the patient residing with PU employee?^*	Yes No
Relative Address^*
Name of the Lab^*
Lab Phone Number^*
Date of Test^*	[dd/mm/yyyy]
Date of Report^*	[dd/mm/yyyy]

Contact person Name^*

Contact person Age^*

Contact person Mobile No.^*

Contact person Department^*

Contact person Address^*

Relation with Covid patient^*

Place of Contact^*

Reason of Contact^*

Duration of Contact^*

[In minutes]

Distance^*

[In meters]

Whether PU employee is
experiencing any COVID
like symptoms^*

Yes No

Enter Captcha^*

Panjab University Chandigarh