Survey.StylesManager.applyTheme("modern");
var json = {
"title": "Minimum data reporting form – for suspected and probable cases of COVID-19",
"pages": [
{
"name": "page1",
"navigationTitle": "Collector",
"navigationDescription": "Collector's info",
"elements": [
{
"type": "image",
"name": "first_page_image",
"imageLink": "/Content/Images/examples/covid/01.png",
"imageFit": "none",
"imageHeight": 726,
"imageWidth": 500,
"width": "600px"
},
{
"type": "panel",
"name": "first_page_container_panel",
"elements": [
{
"type": "text",
"name": "unique_case_id_textbox",
"startWithNewLine": false,
"title": "Unique Case ID / Cluster Number (if applicable):",
"inputType": "number",
"hideNumber": true
},
{
"type": "panel",
"name": "current_status_panel",
"elements": [
{
"type": "boolean",
"name": "current_status",
"titleLocation": "hidden",
"labelTrue": "Alive",
"labelFalse": "Dead",
"hideNumber": true
}
],
"title": "Current Status",
"showNumber": true
},
{
"type": "panel",
"name": "data_collector_information",
"elements": [
{
"type": "text",
"name": "name_of_data_collector",
"title": "Name of data collector"
},
{
"type": "text",
"name": "data_collector_institution",
"title": "Data collector Institution"
},
{
"type": "text",
"name": "data_collector_telephone_number",
"title": "Data collector telephone number",
"inputType": "tel"
},
{
"type": "text",
"name": "email",
"title": "Email",
"inputType": "email"
},
{
"type": "text",
"name": "form_completion_date",
"title": "Form completion date",
"inputType": "date"
}
],
"title": "Data Collector Information",
"showNumber": true,
"showQuestionNumbers": "off"
}
],
"startWithNewLine": false
}
]
},
{
"name": "page2",
"navigationTitle": "Person",
"navigationDescription": "Person's info",
"elements": [
{
"type": "boolean",
"name": "is_the_person_providing_the_information_is_the_patient",
"title": "Is the person providing the information is the patient?",
"isRequired": true,
"labelTrue": "Yes",
"labelFalse": "No",
"hideNumber": true
},
{
"type": "panel",
"name": "case_identifier_information ",
"elements": [
{
"type": "text",
"name": "given_names",
"title": "Given name(s)"
},
{
"type": "text",
"name": "family_name",
"startWithNewLine": false,
"title": "Family name"
},
{
"type": "radiogroup",
"name": "case_identifier_information_sex",
"startWithNewLine": false,
"title": "Sex",
"choices": [
{
"value": "item1",
"text": "Male"
},
{
"value": "item2",
"text": "Female"
},
{
"value": "item3",
"text": "Not known"
}
],
"colCount": 3
},
{
"type": "panel",
"name": "case_identifier_information_patient_date_of_birth_panel",
"elements": [
{
"type": "text",
"name": "case_identifier_information_patient_date_of_birth_date",
"visibleIf": "{case_identifier_information_patient_date_of_birth_checkbox} empty",
"titleLocation": "hidden",
"inputType": "date"
},
{
"type": "checkbox",
"name": "case_identifier_information_patient_date_of_birth_checkbox",
"startWithNewLine": false,
"titleLocation": "hidden",
"choices": [
"Unknown"
]
}
],
"title": "Date of Birth"
},
{
"type": "text",
"name": "case_identifier_information_patient_telephone_mobile_number",
"title": "Telephone (mobile) number",
"inputType": "tel"
},
{
"type": "panel",
"name": "case_identifier_information_patient_age",
"elements": [
{
"type": "text",
"name": "case_identifier_information_patient_age_years",
"visibleIf": "{case_identifier_information_patient_age_checkbox} empty",
"title": "Years:",
"titleLocation": "left",
"inputType": "number"
},
{
"type": "text",
"name": "case_identifier_information_patient_age_months",
"visibleIf": "{case_identifier_information_patient_age_checkbox} empty",
"startWithNewLine": false,
"title": "Months:",
"titleLocation": "left",
"inputType": "number"
},
{
"type": "checkbox",
"name": "case_identifier_information_patient_age_checkbox",
"startWithNewLine": false,
"titleLocation": "hidden",
"choices": [
"Unknown"
]
}
],
"title": "Age (years, months) "
},
{
"type": "text",
"name": "case_identifier_information_patient_email",
"title": "Email",
"inputType": "email"
},
{
"type": "text",
"name": "case_identifier_information_patient_address",
"startWithNewLine": false,
"title": "Address"
},
{
"type": "text",
"name": "case_identifier_information_patient_national_social_number",
"startWithNewLine": false,
"title": "National social number/ identifier (if applicable)"
},
{
"type": "dropdown",
"name": "case_identifier_information_patient_country_of_residence",
"title": "Country of residence",
"choices": [
"item1",
"item2",
"item3"
],
"choicesByUrl": {
"url": "https://restcountries.eu/rest/v2/all",
"valueName": "name"
}
},
{
"type": "radiogroup",
"name": "case_identifier_information_patient_case_status",
"startWithNewLine": false,
"title": "Case status",
"choices": [
{
"value": "item1",
"text": "Suspected"
},
{
"value": "item2",
"text": "Probable"
},
{
"value": "item3",
"text": "Confirmed"
}
],
"colCount": 3
}
],
"visibleIf": "{is_the_person_providing_the_information_is_the_patient} = true",
"title": "Case Identifier Information",
"showNumber": true,
"showQuestionNumbers": "off"
},
{
"type": "panel",
"name": "interview_respondent_information_if_the_persons_providing_the_information_is_not_the_patient",
"elements": [
{
"type": "text",
"name": "first_name",
"title": "First name "
},
{
"type": "text",
"name": "surname",
"startWithNewLine": false,
"title": "Surname"
},
{
"type": "radiogroup",
"name": "interview_respondent_information_sex",
"startWithNewLine": false,
"title": "Sex",
"choices": [
{
"value": "item1",
"text": "Male"
},
{
"value": "item2",
"text": "Female"
},
{
"value": "item3",
"text": "Not known"
}
],
"colCount": 3
},
{
"type": "panel",
"name": "interview_respondent_information_patient_date_of_birth_panel",
"elements": [
{
"type": "text",
"name": "interview_respondent_information_patient_date_of_birth_date",
"visibleIf": "{interview_respondent_information_patient_date_of_birth_checkbox} empty",
"titleLocation": "hidden",
"inputType": "date"
},
{
"type": "checkbox",
"name": "interview_respondent_information_patient_date_of_birth_checkbox",
"startWithNewLine": false,
"titleLocation": "hidden",
"choices": [
"Unknown"
]
}
],
"title": "Date of Birth"
},
{
"type": "text",
"name": "relationship_to_patient",
"title": "Relationship to patient"
},
{
"type": "text",
"name": "respondent_address",
"startWithNewLine": false,
"title": "Respondent address"
},
{
"type": "text",
"name": "interview_respondent_information_patient_telephone_mobile_number",
"startWithNewLine": false,
"title": "Telephone (mobile) number",
"inputType": "tel"
}
],
"visibleIf": "{is_the_person_providing_the_information_is_the_patient} = false",
"title": "Interview respondent information",
"showNumber": true,
"showQuestionNumbers": "off"
}
]
},
{
"name": "page3",
"navigationTitle": "Symptoms",
"navigationDescription": "Patient symptoms",
"elements": [
{
"type": "image",
"name": "third_page_image",
"imageLink": "/Content/Images/examples/covid/03.png",
"imageHeight": 690,
"imageWidth": 500,
"width": "600px"
},
{
"type": "panel",
"name": "patient_symptoms_from_disease_onset",
"elements": [
{
"type": "panel",
"name": "date_of_first_symptom_onset",
"elements": [
{
"type": "text",
"name": "date_of_first_symptom_onset_date",
"enableIf": "{date_of_first_symptom_onset_checkbox} empty",
"titleLocation": "hidden",
"inputType": "date",
"width": "314px"
},
{
"type": "checkbox",
"name": "date_of_first_symptom_onset_checkbox",
"startWithNewLine": false,
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "No symptoms",
"enableIf": "{date_of_first_symptom_onset_checkbox} <> ['item2']"
},
{
"value": "item2",
"text": "Unknown",
"enableIf": "{date_of_first_symptom_onset_checkbox} <> ['item1']"
}
],
"colCount": 2
},
{
"type": "radiogroup",
"name": "question1",
"title": "Fever (≥38 °C) or history of fever ",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
}
],
"title": "Date of first symptom onset"
},
{
"type": "radiogroup",
"name": "sore_throat",
"title": "Sore throat",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "runny_nose",
"title": "Runny nose",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "cough",
"title": "Cough",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "shortness_of_Breath",
"title": "Shortness of Breath",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "vomiting",
"title": "Vomiting",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "nausea",
"title": "Nausea",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "diarrhea",
"title": "Diarrhea",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
}
],
"title": "Patient symptoms (from disease onset)",
"startWithNewLine": false,
"showNumber": true,
"showQuestionNumbers": "off"
}
]
},
{
"name": "page4",
"navigationTitle": "Sample",
"navigationDescription": "Initial sample",
"elements": [
{
"type": "image",
"name": "fouth_page_image",
"width": "600px",
"imageLink": "/Content/Images/examples/covid/04.png",
"imageHeight": 567,
"imageWidth": 500
},
{
"type": "panel",
"name": "initial_sample_collection",
"elements": [
{
"type": "text",
"name": "date_respiratory_sample_collected",
"title": "Date respiratory sample collected",
"inputType": "date"
},
{
"type": "radiogroup",
"name": "what_type_of_respiratory_sample_was_collected",
"title": "What type of respiratory sample was collected?",
"hasOther": true,
"choices": [
{
"value": "item1",
"text": "Nasal swab"
},
{
"value": "item2",
"text": "Throat swab "
},
{
"value": "item3",
"text": "Nasopharyngeal swab"
}
],
"otherText": "Other, specify",
"colCount": 2
},
{
"type": "panel",
"name": "has_baseline_serum_been_taken_panel",
"elements": [
{
"type": "radiogroup",
"name": "has_baseline_serum_been_taken_radio",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "has_baseline_serum_been_taken_date",
"visibleIf": "{has_baseline_serum_been_taken_radio} = 'item1'",
"startWithNewLine": false,
"title": "Date baseline serum taken",
"titleLocation": "left",
"inputType": "date"
}
],
"title": "Has baseline serum been taken?"
},
{
"type": "panel",
"name": "were_other_samples_collected_panel",
"elements": [
{
"type": "radiogroup",
"name": "were_other_samples_collected_radio",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "were_other_samples_collected_textbox",
"visibleIf": "{were_other_samples_collected_radio} = 'item1'",
"startWithNewLine": false,
"title": "Which samples:"
},
{
"type": "text",
"name": "were_other_samples_collected_date",
"visibleIf": "{were_other_samples_collected_radio} = 'item1'",
"startWithNewLine": false,
"title": "Date taken",
"inputType": "date"
}
],
"title": "Were other samples collected? "
}
],
"title": "Initial sample collection",
"startWithNewLine": false,
"showNumber": true,
"showQuestionNumbers": "off"
}
]
},
{
"name": "page5",
"navigationTitle": "Complications",
"navigationDescription": "Clinical Course",
"elements": [
{
"type": "image",
"name": "fifth_image",
"width": "600px",
"imageLink": "/Content/Images/examples/covid/05.png",
"imageHeight": 713,
"imageWidth": 500
},
{
"type": "panel",
"name": "clinical_course_complications_panel",
"elements": [
{
"type": "panel",
"name": "hospitalization_required_panel",
"elements": [
{
"type": "radiogroup",
"name": "hospitalization_required_radio",
"width": "49%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "hospitalization_required_hospital",
"enableIf": "{hospitalization_required_radio} = 'item1'",
"startWithNewLine": false,
"title": "Name of hospital",
"width": "313px",
"titleLocation": "left"
}
],
"title": "Hospitalization required?"
},
{
"type": "radiogroup",
"name": "icu_Intensive_Care_Unit_admission_required",
"title": "ICU (Intensive Care Unit) admission required",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "acute_respiratory_distress_syndrome_ards",
"title": "Acute Respiratory Distress Syndrome (ARDS)",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "panel",
"name": "pneumonia_by_chest_xray_panel",
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{
"type": "radiogroup",
"name": "pneumonia_by_chest_xray_radio",
"width": "49%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Not applicable (no X-ray performed)"
}
],
"colCount": 3
},
{
"type": "text",
"name": "pneumonia_by_chest_xray_date",
"enableIf": "{pneumonia_by_chest_xray_radio} = 'item1'",
"startWithNewLine": false,
"title": "Date",
"titleLocation": "left",
"width": "313px",
"inputType": "date"
}
],
"title": "Pneumonia by chest X-ray "
},
{
"type": "panel",
"name": "other_severe_or_life_threatening_illness_suggestive_of_an_infection_panel",
"elements": [
{
"type": "radiogroup",
"name": "other_severe_or_life_threatening_illness_suggestive_of_an_radio",
"width": "49%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "other_severe_or_life_threatening_illness_suggestive_of_an_specify",
"enableIf": "{other_severe_or_life_threatening_illness_suggestive_of_an_radio} = 'item1'",
"startWithNewLine": false,
"title": "Specify:",
"width": "313px",
"titleLocation": "left"
}
],
"title": "Other severe or life-threatening illness suggestive of an infection"
},
{
"type": "radiogroup",
"name": "mechanical_ventilation_required",
"title": "Mechanical ventilation required",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "extracorporeal_membrane_oxygenation_emo",
"title": "Extracorporeal membrane oxygenation (EMO)",
"titleLocation": "left",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
}
],
"title": "Clinical Course: Complications",
"startWithNewLine": false,
"showNumber": true,
"showQuestionNumbers": "off"
}
]
},
{
"name": "page6",
"navigationTitle": "Exposures",
"navigationDescription": "Before illness",
"elements": [
{
"type": "panel",
"name": "human_exposures_in_the_days_before_illness_onset",
"elements": [
{
"type": "panel",
"name": "have_you_travelled_within_the_last_days_domestically_panel",
"elements": [
{
"type": "radiogroup",
"name": "have_you_travelled_within_the_last_days_domestically_radio",
"width": "50%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "panel",
"name": "have_you_travelled_within_the_last_days_domestically_date_panel",
"elements": [
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_domestically_date_from",
"title": "from",
"titleLocation": "left",
"inputType": "date"
},
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_domestically_date_to",
"startWithNewLine": false,
"title": "to",
"titleLocation": "left",
"inputType": "date"
}
],
"visibleIf": "{have_you_travelled_within_the_last_days_domestically_radio} = 'item1'",
"title": "Dates of travel"
},
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_domestically_regions",
"visibleIf": "{have_you_travelled_within_the_last_days_domestically_radio} = 'item1'",
"title": "Regions:",
"titleLocation": "left"
},
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_domestically_cities_visited",
"visibleIf": "{have_you_travelled_within_the_last_days_domestically_radio} = 'item1'",
"startWithNewLine": false,
"title": "Cities visited:",
"titleLocation": "left"
}
],
"title": "Have you travelled within the last 14 days domestically?",
"showQuestionNumbers": "off"
},
{
"type": "panel",
"name": "have_you_travelled_within_the_last_days_internationall_panel",
"elements": [
{
"type": "radiogroup",
"name": "have_you_travelled_within_the_last_days_internationall_radio",
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"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "panel",
"name": "have_you_travelled_within_the_last_days_internationall_date_panel",
"elements": [
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_internationall_date_from",
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"inputType": "date"
},
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_internationall_date_to",
"startWithNewLine": false,
"title": "to",
"titleLocation": "left",
"inputType": "date"
}
],
"visibleIf": "{have_you_travelled_within_the_last_days_internationall_radio} = 'item1'",
"title": "Dates of travel"
},
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_internationall_countries",
"visibleIf": "{have_you_travelled_within_the_last_days_internationall_radio} = 'item1'",
"title": "Countries visited:",
"titleLocation": "left"
},
{
"type": "text",
"name": "have_you_travelled_within_the_last_days_internationall_cities",
"visibleIf": "{have_you_travelled_within_the_last_days_internationall_radio} = 'item1'",
"startWithNewLine": false,
"title": "Cities visited:",
"titleLocation": "left"
}
],
"title": "Have you travelled within the last 14 days internationally?",
"showQuestionNumbers": "off"
},
{
"type": "panel",
"name": "in_the_past_days_have_you_had_contact_with_a_anyone_with_suspected_or_confirmed_ncov_infection_panel",
"elements": [
{
"type": "radiogroup",
"name": "in_the_past_days_have_you_had_contact_with_a_anyone_with_suspected_or_confirmed_ncov_infection_radio",
"width": "50%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "in_the_past_days_have_you_had_contact_with_a_anyone_with_suspected_or_confirmed_ncov_infection_date",
"enableIf": "{in_the_past_days_have_you_had_contact_with_a_anyone_with_suspected_or_confirmed_ncov_infection_radio} = 'item1'",
"startWithNewLine": false,
"title": "Date of last contact",
"titleLocation": "left",
"inputType": "date"
}
],
"title": "In the past 14 days, have you had contact with a anyone with suspected or confirmed 2019-nCoV infection?",
"showQuestionNumbers": "off"
},
{
"type": "panel",
"name": "patient_attended_festival_or_mass_gathering_panel",
"elements": [
{
"type": "radiogroup",
"name": "patient_attended_festival_or_mass_gathering_radio",
"width": "50%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "patient_attended_festival_or_mass_gathering_specify",
"enableIf": "{patient_attended_festival_or_mass_gathering_radio} = 'item1'",
"startWithNewLine": false,
"title": "Specify:",
"titleLocation": "left"
}
],
"title": "Patient attended festival or mass gathering",
"showQuestionNumbers": "off"
},
{
"type": "radiogroup",
"name": "patient_exposed_to_person_with_similar_illness",
"title": "Patient exposed to person with similar illness",
"width": "50%",
"hideNumber": true,
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "location_of_exposure",
"title": "Location of exposure",
"width": "50%",
"hideNumber": true,
"hasOther": true,
"choices": [
{
"value": "item1",
"text": "Home"
},
{
"value": "item2",
"text": "Hospital"
},
{
"value": "item3",
"text": "Workplace"
},
{
"value": "item4",
"text": "Tour group"
},
{
"value": "item5",
"text": "Unknown"
}
],
"otherText": "Other, specify:",
"colCount": 3
},
{
"type": "panel",
"name": "patient_visited_or_was_admitted_to_inpatient_health_facility_panel",
"elements": [
{
"type": "radiogroup",
"name": "patient_visited_or_was_admitted_to_inpatient_health_facility_radio",
"width": "50%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "patient_visited_or_was_admitted_to_inpatient_health_facility_specify",
"enableIf": "{patient_visited_or_was_admitted_to_inpatient_health_facility_radio} = 'item1'",
"startWithNewLine": false,
"title": "Specify:",
"titleLocation": "left"
},
{
"type": "panel",
"name": "patient_visited_outpatient_treatment_facility_panel",
"elements": [
{
"type": "radiogroup",
"name": "patient_visited_outpatient_treatment_facility_radio",
"width": "50%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "patient_visited_outpatient_treatment_facility_specify",
"enableIf": "{patient_visited_outpatient_treatment_facility_radio} = 'item1'",
"startWithNewLine": false,
"title": "Specify:",
"titleLocation": "left"
}
],
"title": "Patient visited outpatient treatment facility"
},
{
"type": "panel",
"name": "patient_visited_traditional_healer_panel",
"elements": [
{
"type": "radiogroup",
"name": "patient_visited_traditional_healer_radio",
"width": "50%",
"titleLocation": "hidden",
"choices": [
{
"value": "item1",
"text": "Yes"
},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
"colCount": 3
},
{
"type": "text",
"name": "patient_visited_traditional_healer_specify",
"enableIf": "{patient_visited_traditional_healer_radio} = 'item1'",
"startWithNewLine": false,
"title": "Specify:",
"titleLocation": "left"
},
{
"type": "panel",
"name": "patient_occupation_specify_location_facility_panel",
"elements": [
{
"type": "checkbox",
"name": "patient_occupation_specify_location_facility_checkbox",
"titleLocation": "hidden",
"hasOther": true,
"choices": [
{
"value": "item1",
"text": "Health care worker"
},
{
"value": "item2",
"text": "Working with animals "
},
{
"value": "item3",
"text": "Health laboratory worker"
},
{
"value": "item4",
"text": "Student"
}
],
"otherText": "Other, specify:",
"colCount": 3
},
{
"type": "text",
"name": "patient_occupation_specify_location_facility_specify",
"visibleIf": "{patient_occupation_specify_location_facility_checkbox} notempty",
"title": "For each occupation, please specify location or facility:",
"titleLocation": "left"
}
],
"title": "Patient occupation (specify location/facility)",
"showQuestionNumbers": "off"
}
],
"title": "Patient visited traditional healer"
}
],
"title": "Patient visited or was admitted to inpatient health facility",
"showQuestionNumbers": "off"
}
],
"title": "Human exposures in the 14 days before illness onset",
"showNumber": true
}
]
},
{
"name": "page7",
"navigationTitle": "Completion",
"navigationDescription": "Status of form",
"elements": [
{
"type": "image",
"name": "seventh_image",
"width": "600",
"imageLink": "/Content/Images/examples/covid/07.png",
"imageHeight": 441,
"imageWidth": 500
},
{
"type": "panel",
"name": "status_of_form_completion_panel",
"elements": [
{
"type": "boolean",
"name": "status_of_form_completion_boolean",
"title": "Form completed",
"isRequired": true,
"labelTrue": "Yes",
"labelFalse": "No or partially"
},
{
"type": "radiogroup",
"name": "status_of_form_completion_radio",
"visibleIf": "{status_of_form_completion_boolean} = false",
"title": "Reason:",
"hasOther": true,
"choices": [
{
"value": "item1",
"text": "Missed"
},
{
"value": "item2",
"text": "Not attempted"
},
{
"value": "item3",
"text": "Not performed"
},
{
"value": "item4",
"text": "Refusal"
}
],
"otherText": "Other, specific:"
}
],
"title": "Status of form completion",
"startWithNewLine": false,
"showNumber": true,
"showQuestionNumbers": "off"
}
]
}
],
"showProgressBar": "top",
"progressBarType": "buttons"
};
window.survey = new Survey.Model(json);
survey.onComplete.add(function(sender) {
document.querySelector('#surveyResult').textContent =
"Result JSON:\n" + JSON.stringify(sender.data, null, 3);
});
var app = new Vue({
el: '#surveyElement',
data:
{
survey: survey
}
});
