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v 1.9.0
v 1.9.0
Overview Survey Creator Survey Creator V2 Examples Docs Source

COVID-19


                        
    
        SurveyCreator.StylesManager.applyTheme("bootstrap");
    


            
                var creatorOptions = { showLogicTab: true };
                var creator = new SurveyCreator.SurveyCreator("creatorElement", creatorOptions);
                creator.showToolbox = "right";
                creator.showPropertyGrid = "right";
                creator.rightContainerActiveItem("toolbox");
            
creator.JSON = {
 "title": "Minimum data reporting form – for suspected and probable cases of COVID-19",
 "pages": [
  {
   "name": "page1",
   "elements": [
    {
     "type": "image",
     "name": "first_page_image",
     "width": "600px",
     "minWidth": "600px",
     "maxWidth": "600px",
     "imageLink": "/Content/Images/examples/covid/01.png",
     "imageFit": "none",
     "imageHeight": 726,
     "imageWidth": 500
    },
    {
     "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):",
       "hideNumber": true,
       "inputType": "number"
      },
      {
       "type": "panel",
       "name": "current_status_panel",
       "elements": [
        {
         "type": "boolean",
         "name": "current_status",
         "titleLocation": "hidden",
         "hideNumber": true,
         "labelTrue": "Alive",
         "labelFalse": "Dead"
        }
       ],
       "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
    }
   ],
   "navigationTitle": "Collector",
   "navigationDescription": "Collector's info"
  },
  {
   "name": "page2",
   "elements": [
    {
     "type": "boolean",
     "name": "is_the_person_providing_the_information_is_the_patient",
     "title": "Is the person providing the information is the patient?",
     "hideNumber": true,
     "isRequired": true,
     "labelTrue": "Yes",
     "labelFalse": "No"
    },
    {
     "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": "default",
         "inputType": "number"
        },
        {
         "type": "text",
         "name": "case_identifier_information_patient_age_months",
         "visibleIf": "{case_identifier_information_patient_age_checkbox} empty",
         "startWithNewLine": false,
         "title": "Months:",
         "titleLocation": "default",
         "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://surveyjs.io/api/CountriesExample",
        "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
      }
     ],
     "visible": false,
     "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"
      }
     ],
     "visible": false,
     "visibleIf": "{is_the_person_providing_the_information_is_the_patient} = false",
     "title": "Interview respondent information",
     "showNumber": true,
     "showQuestionNumbers": "off"
    }
   ],
   "navigationTitle": "Person",
   "navigationDescription": "Person's info"
  },
  {
   "name": "page3",
   "elements": [
    {
     "type": "image",
     "name": "third_page_image",
     "width": "600px",
     "imageLink": "/Content/Images/examples/covid/03.png",
     "imageHeight": 690,
     "imageWidth": 500
    },
    {
     "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",
         "width": "314px",
         "titleLocation": "hidden",
         "enableIf": "{date_of_first_symptom_onset_checkbox} empty",
         "inputType": "date"
        },
        {
         "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": "default",
         "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": "default",
       "choices": [
        {
         "value": "item1",
         "text": "Yes"
        },
        {
         "value": "item2",
         "text": "No"
        },
        {
         "value": "item3",
         "text": "Unknown"
        }
       ],
       "colCount": 3
      },
      {
       "type": "radiogroup",
       "name": "runny_nose",
       "title": "Runny nose",
       "titleLocation": "default",
       "choices": [
        {
         "value": "item1",
         "text": "Yes"
        },
        {
         "value": "item2",
         "text": "No"
        },
        {
         "value": "item3",
         "text": "Unknown"
        }
       ],
       "colCount": 3
      },
      {
       "type": "radiogroup",
       "name": "cough",
       "title": "Cough",
       "titleLocation": "default",
       "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": "default",
       "choices": [
        {
         "value": "item1",
         "text": "Yes"
        },
        {
         "value": "item2",
         "text": "No"
        },
        {
         "value": "item3",
         "text": "Unknown"
        }
       ],
       "colCount": 3
      },
      {
       "type": "radiogroup",
       "name": "vomiting",
       "title": "Vomiting",
       "titleLocation": "default",
       "choices": [
        {
         "value": "item1",
         "text": "Yes"
        },
        {
         "value": "item2",
         "text": "No"
        },
        {
         "value": "item3",
         "text": "Unknown"
        }
       ],
       "colCount": 3
      },
      {
       "type": "radiogroup",
       "name": "nausea",
       "title": "Nausea",
       "titleLocation": "default",
       "choices": [
        {
         "value": "item1",
         "text": "Yes"
        },
        {
         "value": "item2",
         "text": "No"
        },
        {
         "value": "item3",
         "text": "Unknown"
        }
       ],
       "colCount": 3
      },
      {
       "type": "radiogroup",
       "name": "diarrhea",
       "title": "Diarrhea",
       "titleLocation": "default",
       "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"
    }
   ],
   "navigationTitle": "Symptoms",
   "navigationDescription": "Patient symptoms"
  },
  {
   "name": "page4",
   "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?",
       "choices": [
        {
         "value": "item1",
         "text": "Nasal swab"
        },
        {
         "value": "item2",
         "text": "Throat swab "
        },
        {
         "value": "item3",
         "text": "Nasopharyngeal swab"
        }
       ],
       "hasOther": true,
       "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",
         "visible": false,
         "visibleIf": "{has_baseline_serum_been_taken_radio} = 'item1'",
         "startWithNewLine": false,
         "title": "Date baseline serum taken",
         "titleLocation": "default",
         "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",
         "visible": false,
         "visibleIf": "{were_other_samples_collected_radio} = 'item1'",
         "startWithNewLine": false,
         "title": "Which samples:"
        },
        {
         "type": "text",
         "name": "were_other_samples_collected_date",
         "visible": false,
         "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"
    }
   ],
   "navigationTitle": "Sample",
   "navigationDescription": "Initial sample"
  },
  {
   "name": "page5",
   "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",
         "width": "313px",
         "startWithNewLine": false,
         "title": "Name of hospital",
         "titleLocation": "default",
         "enableIf": "{hospitalization_required_radio} = 'item1'",
         "readOnly": true
        }
       ],
       "title": "Hospitalization required?"
      },
      {
       "type": "radiogroup",
       "name": "icu_Intensive_Care_Unit_admission_required",
       "title": "ICU (Intensive Care Unit) admission required",
       "titleLocation": "default",
       "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": "default",
       "choices": [
        {
         "value": "item1",
         "text": "Yes"
        },
        {
         "value": "item2",
         "text": "No"
        },
        {
         "value": "item3",
         "text": "Unknown"
        }
       ],
       "colCount": 3
      },
      {
       "type": "panel",
       "name": "pneumonia_by_chest_xray_panel",
       "elements": [
        {
         "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",
         "width": "313px",
         "startWithNewLine": false,
         "title": "Date",
         "titleLocation": "default",
         "enableIf": "{pneumonia_by_chest_xray_radio} = 'item1'",
         "readOnly": true,
         "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",
         "width": "313px",
         "startWithNewLine": false,
         "title": "Specify:",
         "titleLocation": "default",
         "enableIf": "{other_severe_or_life_threatening_illness_suggestive_of_an_radio} = 'item1'",
         "readOnly": true
        }
       ],
       "title": "Other severe or life-threatening illness suggestive of an infection"
      },
      {
       "type": "radiogroup",
       "name": "mechanical_ventilation_required",
       "title": "Mechanical ventilation required",
       "titleLocation": "default",
       "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": "default",
       "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"
    }
   ],
   "navigationTitle": "Complications",
   "navigationDescription": "Clinical Course"
  },
  {
   "name": "page6",
   "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": "default",
           "inputType": "date"
          },
          {
           "type": "text",
           "name": "have_you_travelled_within_the_last_days_domestically_date_to",
           "startWithNewLine": false,
           "title": "to",
           "titleLocation": "default",
           "inputType": "date"
          }
         ],
         "visible": false,
         "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",
         "visible": false,
         "visibleIf": "{have_you_travelled_within_the_last_days_domestically_radio} = 'item1'",
         "title": "Regions:",
         "titleLocation": "default"
        },
        {
         "type": "text",
         "name": "have_you_travelled_within_the_last_days_domestically_cities_visited",
         "visible": false,
         "visibleIf": "{have_you_travelled_within_the_last_days_domestically_radio} = 'item1'",
         "startWithNewLine": false,
         "title": "Cities visited:",
         "titleLocation": "default"
        }
       ],
       "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": [
        {
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          {
           "value": "item1",
           "text": "Yes"
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          {
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           "value": "item3",
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          },
          {
           "type": "text",
           "name": "have_you_travelled_within_the_last_days_internationall_date_to",
           "startWithNewLine": false,
           "title": "to",
           "titleLocation": "default",
           "inputType": "date"
          }
         ],
         "visible": false,
         "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",
         "visible": false,
         "visibleIf": "{have_you_travelled_within_the_last_days_internationall_radio} = 'item1'",
         "title": "Countries visited:",
         "titleLocation": "default"
        },
        {
         "type": "text",
         "name": "have_you_travelled_within_the_last_days_internationall_cities",
         "visible": false,
         "visibleIf": "{have_you_travelled_within_the_last_days_internationall_radio} = 'item1'",
         "startWithNewLine": false,
         "title": "Cities visited:",
         "titleLocation": "default"
        }
       ],
       "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",
         "startWithNewLine": false,
         "title": "Date of last contact",
         "titleLocation": "default",
         "enableIf": "{in_the_past_days_have_you_had_contact_with_a_anyone_with_suspected_or_confirmed_ncov_infection_radio} = 'item1'",
         "readOnly": true,
         "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",
         "startWithNewLine": false,
         "title": "Specify:",
         "titleLocation": "default",
         "enableIf": "{patient_attended_festival_or_mass_gathering_radio} = 'item1'",
         "readOnly": true
        }
       ],
       "title": "Patient attended festival or mass gathering",
       "showQuestionNumbers": "off"
      },
      {
       "type": "radiogroup",
       "name": "patient_exposed_to_person_with_similar_illness",
       "width": "50%",
       "title": "Patient exposed to person with similar illness",
       "hideNumber": true,
       "choices": [
        {
         "value": "item1",
         "text": "Yes"
        },
        {
         "value": "item2",
         "text": "No"
        },
        {
         "value": "item3",
         "text": "Unknown"
        }
       ],
       "colCount": 3
      },
      {
       "type": "radiogroup",
       "name": "location_of_exposure",
       "width": "50%",
       "title": "Location of exposure",
       "hideNumber": true,
       "choices": [
        {
         "value": "item1",
         "text": "Home"
        },
        {
         "value": "item2",
         "text": "Hospital"
        },
        {
         "value": "item3",
         "text": "Workplace"
        },
        {
         "value": "item4",
         "text": "Tour group"
        },
        {
         "value": "item5",
         "text": "Unknown"
        }
       ],
       "hasOther": true,
       "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",
         "startWithNewLine": false,
         "title": "Specify:",
         "titleLocation": "default",
         "enableIf": "{patient_visited_or_was_admitted_to_inpatient_health_facility_radio} = 'item1'",
         "readOnly": true
        },
        {
         "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",
           "startWithNewLine": false,
           "title": "Specify:",
           "titleLocation": "default",
           "enableIf": "{patient_visited_outpatient_treatment_facility_radio} = 'item1'",
           "readOnly": true
          }
         ],
         "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",
           "startWithNewLine": false,
           "title": "Specify:",
           "titleLocation": "default",
           "enableIf": "{patient_visited_traditional_healer_radio} = 'item1'",
           "readOnly": true
          },
          {
           "type": "panel",
           "name": "patient_occupation_specify_location_facility_panel",
           "elements": [
            {
             "type": "checkbox",
             "name": "patient_occupation_specify_location_facility_checkbox",
             "titleLocation": "hidden",
             "choices": [
              {
               "value": "item1",
               "text": "Health care worker"
              },
              {
               "value": "item2",
               "text": "Working with animals "
              },
              {
               "value": "item3",
               "text": "Health laboratory worker"
              },
              {
               "value": "item4",
               "text": "Student"
              }
             ],
             "hasOther": true,
             "otherText": "Other, specify:",
             "colCount": 3
            },
            {
             "type": "text",
             "name": "patient_occupation_specify_location_facility_specify",
             "visible": false,
             "visibleIf": "{patient_occupation_specify_location_facility_checkbox} notempty",
             "title": "For each occupation, please specify location or facility:",
             "titleLocation": "default"
            }
           ],
           "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
    }
   ],
   "navigationTitle": "Exposures",
   "navigationDescription": "Before illness"
  },
  {
   "name": "page7",
   "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",
       "visible": false,
       "visibleIf": "{status_of_form_completion_boolean} = false",
       "title": "Reason:",
       "choices": [
        {
         "value": "item1",
         "text": "Missed"
        },
        {
         "value": "item2",
         "text": "Not attempted"
        },
        {
         "value": "item3",
         "text": "Not performed"
        },
        {
         "value": "item4",
         "text": "Refusal"
        }
       ],
       "hasOther": true,
       "otherText": "Other, specific:"
      }
     ],
     "title": "Status of form completion",
     "startWithNewLine": false,
     "showNumber": true,
     "showQuestionNumbers": "off"
    }
   ],
   "navigationTitle": "Completion",
   "navigationDescription": "Status of form"
  }
 ],
 "showProgressBar": "top",
 "progressBarType": "buttons"
};
                    
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<head>
    <title>, Survey Creator Example</title>

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