| Pregnancy with COVID 19 Study

Pregnancy with COVID 19 Form

State*  
City *  
Name of the Hospital*  
Total number of ICU Bed*  
Total number of Hospital Beds*  
Total number of patients admitted in ICU during the study period in the centre
Total number of patients admitted in the hospital during that period.

HOSPITAL DEMOGRAPHICS

Type of hospital *  
Public  
Private  

INVESTIGATOR INFORMATION

(Up to two investigator can be Registered per ICU)

Details of Principle Investigator

First Name*  
Last Name*  
Email Id*    
Mobile no*  

Details of Co Investigator 1

First Name*  
Last Name*  
Email Id*    
Mobile No*  

Details of Co Investigator 2

First Name
Last Name
Email Id  
Mobile No

Address of Hospital

Address 1*  
Address 2 *  
Address 3
City *  
State*  
Pincode *  

Contact details of hospital

Email Id*    
Alternate Email  
Contact Number*  
Alternate Contact Number