FORM OF INFORMATION –COVID-19

Employee No & Name: 3 0

Aadhar No
Residential Address

Salary Grade

Unit

Dept.

Reporting Officer Date Last Reported 2020

List of Contacts 2 days prior to last reported to duty

S.No. Emp. No Name Department

1
2
3
4
5

Symptoms (please tick appropriate) :

Fever Dry Cough Breathlessness Body Pains Fever others

If Others Please Specify

Date & Result of COVID test :

Details of Family Members if COVID Positive :

SNo Name Relation Address
1
2
3
4
5

Sign of Employee Date Submitted 2020