Survey.StylesManager.applyTheme("modern");
var json = {
"title": "Minimum data reporting form – for suspected and probable cases of COVID-19",
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{
"name": "page1",
"navigationTitle": "Collector",
"navigationDescription": "Collector's info",
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"imageLink": "https://surveyjs.io/Content/Images/examples/covid/01.png",
"imageFit": "none",
"imageHeight": 726,
"imageWidth": 400
},
{
"type": "panel",
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{
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"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",
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"showQuestionNumbers": "off"
}
],
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}
]
},
{
"name": "page2",
"navigationTitle": "Person",
"navigationDescription": "Person's info",
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{
"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",
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"title": "Family name"
},
{
"type": "radiogroup",
"name": "case_identifier_information_sex",
"title": "Sex",
"choices": [
{
"value": "item1",
"text": "Male"
},
{
"value": "item2",
"text": "Female"
},
{
"value": "item3",
"text": "Not known"
}
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{
"type": "panel",
"name": "case_identifier_information_patient_date_of_birth_panel",
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{
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},
{
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"name": "case_identifier_information_patient_date_of_birth_checkbox",
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"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:",
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"inputType": "number"
},
{
"type": "text",
"name": "case_identifier_information_patient_age_months",
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"title": "Months:",
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},
{
"type": "checkbox",
"name": "case_identifier_information_patient_age_checkbox",
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"titleLocation": "hidden",
"choices": [
"Unknown"
]
}
],
"title": "Age (years, months) "
},
{
"type": "text",
"name": "case_identifier_information_patient_email",
"title": "Email",
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{
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"title": "Address"
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{
"type": "text",
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"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://surveyjs.io/api/CountriesExample",
"valueName": "name"
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{
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"name": "case_identifier_information_patient_case_status",
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"title": "Case status",
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{
"value": "item1",
"text": "Suspected"
},
{
"value": "item2",
"text": "Probable"
},
{
"value": "item3",
"text": "Confirmed"
}
],
"colCount": 3
}
],
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"title": "Case Identifier Information",
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{
"type": "panel",
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{
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{
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{
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{
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},
{
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"Unknown"
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}
],
"title": "Date of Birth"
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{
"type": "text",
"name": "relationship_to_patient",
"title": "Relationship to patient"
},
{
"type": "text",
"name": "respondent_address",
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"title": "Respondent address"
},
{
"type": "text",
"name": "interview_respondent_information_patient_telephone_mobile_number",
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"title": "Telephone (mobile) number",
"inputType": "tel"
}
],
"visibleIf": "{is_the_person_providing_the_information_is_the_patient} = false",
"title": "Interview respondent information",
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]
},
{
"name": "page3",
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"imageLink": "https://surveyjs.io/Content/Images/examples/covid/03.png",
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},
{
"type": "panel",
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"elements": [
{
"type": "panel",
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{
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"width": "314px"
},
{
"type": "checkbox",
"name": "date_of_first_symptom_onset_checkbox",
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"choices": [
{
"value": "item1",
"text": "No symptoms",
"enableIf": "{date_of_first_symptom_onset_checkbox} <> ['item2']"
},
{
"value": "item2",
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}
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{
"type": "radiogroup",
"name": "question1",
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{
"value": "item1",
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{
"value": "item2",
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{
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],
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],
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},
{
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"name": "sore_throat",
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{
"value": "item1",
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{
"value": "item2",
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},
{
"value": "item3",
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],
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{
"type": "radiogroup",
"name": "runny_nose",
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{
"value": "item1",
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},
{
"value": "item2",
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},
{
"value": "item3",
"text": "Unknown"
}
],
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{
"type": "radiogroup",
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{
"value": "item1",
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},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
],
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},
{
"type": "radiogroup",
"name": "shortness_of_Breath",
"title": "Shortness of Breath",
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{
"value": "item1",
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},
{
"value": "item2",
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{
"value": "item3",
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{
"type": "radiogroup",
"name": "vomiting",
"title": "Vomiting",
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{
"value": "item1",
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},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
"text": "Unknown"
}
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{
"type": "radiogroup",
"name": "nausea",
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{
"value": "item1",
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},
{
"value": "item2",
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},
{
"value": "item3",
"text": "Unknown"
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],
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{
"type": "radiogroup",
"name": "diarrhea",
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{
"value": "item1",
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},
{
"value": "item2",
"text": "No"
},
{
"value": "item3",
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],
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}
],
"title": "Patient symptoms (from disease onset)",
"startWithNewLine": false,
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}
]
},
{
"name": "page4",
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"imageHeight": 567,
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},
{
"type": "panel",
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{
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{
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},
{
"value": "item2",
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{
"value": "item3",
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}
],
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},
{
"type": "panel",
"name": "has_baseline_serum_been_taken_panel",
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{
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{
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{
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{
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}
],
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},
{
"type": "panel",
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{
"type": "radiogroup",
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"value": "item1",
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{
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},
{
"type": "text",
"name": "were_other_samples_collected_date",
"visibleIf": "{were_other_samples_collected_radio} = 'item1'",
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}
],
"title": "Were other samples collected? "
}
],
"title": "Initial sample collection",
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"showNumber": true,
"showQuestionNumbers": "off"
}
]
},
{
"name": "page5",
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"type": "image",
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},
{
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{
"type": "panel",
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{
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}
],
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},
{
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"name": "icu_Intensive_Care_Unit_admission_required",
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"value": "item1",
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{
"value": "item2",
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{
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"value": "item1",
"text": "Yes"
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{
"value": "item2",
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{
"value": "item3",
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{
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{
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},
{
"value": "item3",
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}
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{
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"inputType": "date"
}
],
"title": "Pneumonia by chest X-ray "
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{
"type": "panel",
"name": "other_severe_or_life_threatening_illness_suggestive_of_an_infection_panel",
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{
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}
],
"title": "Other severe or life-threatening illness suggestive of an infection"
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{
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"value": "item1",
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{
"value": "item2",
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{
"type": "radiogroup",
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"value": "item1",
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},
{
"value": "item2",
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},
{
"value": "item3",
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],
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],
"title": "Clinical Course: Complications",
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]
},
{
"name": "page6",
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{
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{
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{
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{
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],
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{
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},
{
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"title": "Cities visited:",
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}
],
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{
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{
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{
"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": "400px",
"minWidth": "400px",
"maxWidth": "400px",
"imageLink": "https://surveyjs.io/Content/Images/examples/covid/07.png",
"imageHeight": 441,
"imageWidth": 400
},
{
"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
}
});
<!DOCTYPE html>
<html lang="en">
<head>
<title>COVID-19, Vue Survey Library Example</title>
<meta name="viewport" content="width=device-width" />
<script src="https://unpkg.com/vue@2.6.14/dist/vue.js"></script>
<script src="/DevBuilds/survey-core/survey.core.min.js"></script>
<script src="/DevBuilds/survey-core/survey.i18n.min.js"></script>
<script src="/DevBuilds/survey-vue-ui/survey-vue-ui.min.js"></script>
<link href="/DevBuilds/survey-core/modern.min.css" type="text/css" rel="stylesheet" />
<link rel="stylesheet" href="./index.css">
</head>
<body style="margin: 0">
<div id="surveyElement" style="display:inline-block;width:100%;">
<survey :survey='survey' />
</div>
<div id="surveyResult"></div>
<script type="text/javascript" src="./index.js"></script>
</body>
</html>
Help us serve you better by taking this brief survey.
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experience of using our libraries.
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