C19 Immunization eform - as a regular json file
=================================================
{ "_id": "60e39019fe193cf38a1044d9", "type": "form", "tags": [ "publish" ], "owner": "60dcf29ae886a997f0ff54c4", "components": [ { "label": "Columns", "columns": [ { "components": [ { "label": "Service Delivery Location", "widget": "choicesjs", "description": "This is the location of the COVID-19 Immunization Clinic where the client received vaccine. If your SDL is not found, select the closest city/town.", "tableView": true, "dataSrc": "url", "data": { "url": "https://api.eforms.phsaehealth.ca/sdls.json", "headers": [ { "key": "", "value": "" } ] }, "valueProperty": "value", "selectThreshold": 0.3, "customOptions": { "searchResultLimit": 7 }, "validate": { "required": true }, "key": "serviceDeliveryLocation", "properties": { "class": "service.delivery.location", "questionnaireElement": "serviceDeliveryLocation", "settings": "coding" }, "type": "select", "input": true, "hideOnChildrenHidden": false, "disableLimit": false } ], "width": 8, "offset": 0, "push": 0, "pull": 0, "size": "md", "currentWidth": 8 }, { "components": [
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
}
],
"key": "columns7",
"type": "columns",
"input": false,
"tableView": false
},
{
"title": "Client Demographics",
"collapsible": false,
"key": "clientDemographics",
"properties": {
"formioResource": "patientInformation",
"fhirResource": "Patient"
},
"type": "panel",
"label": "Client Demographics",
"input": false,
"tableView": false,
"components": [
{
"label": "Patient Demographics",
"tableView": false,
"key": "patientDemographicsWell",
"type": "well",
"input": false,
"components": [
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Last Name",
"tooltip": "Please include full legal name",
"tableView": true,
"validate": {
"required": true
},
"key": "patientNameFamily",
"properties": {
"class": "last.name",
"fhirElement": "Patient.name.where(use='official').family"
},
"overlay": {
"page": "1",
"left": "0",
"top": "0",
"width": "150",
"height": "20"
},
"type": "textfield",
"labelWidth": 30,
"labelMargin": 3,
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "First Name",
"tooltip": "Please include full legal name",
"tableView": true,
"validate": {
"required": true
},
"key": "patientNameGiven",
"properties": {
"class": "first.name",
"fhirElement": "Patient.name.where(use='official').given"
},
"overlay": {
"page": "1",
"left": "190",
"top": "0",
"width": "150",
"height": "20"
},
"type": "textfield",
"labelWidth": 30,
"labelMargin": 3,
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "Middle Name",
"tableView": true,
"key": "patientNameGivenMiddle",
"properties": {
"class": "middle.name",
"fhirElement": "Patient.name.where(use='official').given[1]"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "BC PHN",
"tooltip": "BC Personal Health Number",
"inputMask": "9999999999",
"tableView": true,
"validate": {
"maxLength": 10,
"minLength": null
},
"key": "patientIdentifier",
"properties": {
"class": "phn",
"fhirElement": "Patient.identifier.where(system.endsWith('ca-bc-patient-healthcare-id')).value"
},
"type": "textfield",
"labelWidth": 30,
"labelMargin": 3,
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
}
],
"hideLabel": true,
"key": "columns11",
"type": "columns",
"tableView": false,
"input": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Date of Birth",
"widget": {
"type": "calendar",
"altInput": true,
"allowInput": true,
"clickOpens": true,
"enableDate": true,
"enableTime": false,
"mode": "single",
"noCalendar": false,
"format": "yyyy-MM-dd",
"dateFormat": "yyyy-MM-dd",
"useLocaleSettings": false,
"hourIncrement": 1,
"minuteIncrement": 5,
"time_24hr": false,
"saveAs": "date",
"maxDate": "moment()",
"locale": "en"
},
"tableView": true,
"validate": {
"required": true
},
"key": "patientBirthDate",
"properties": {
"class": "birthDate",
"fhirElement": "Patient.birthDate"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "Sex",
"optionsLabelPosition": "right",
"inline": true,
"tableView": true,
"values": [
{
"value": "male",
"label": "Male",
"shortcut": ""
},
{
"value": "female",
"label": "Female",
"shortcut": ""
},
{
"value": "undifferentiated",
"label": "Undifferentiated",
"shortcut": ""
},
{
"value": "unknown",
"label": "Unknown",
"shortcut": ""
}
],
"validate": {
"required": true
},
"key": "patientGender",
"properties": {
"class": "gender",
"fhirElement": "Patient.gender"
},
"type": "radio",
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
},
{
"components": [
{
"label": "Home Phone Number",
"description": "Please confirm and update to most recent phone number",
"inputMask": "999-999-9999",
"tableView": true,
"key": "patientPrimaryPhoneNumber",
"properties": {
"class": "phone",
"fhirElement": "Patient.telecom.where(use='home' and system='phone').value"
},
"overlay": {
"page": "1",
"left": "760",
"top": "0",
"width": "150",
"height": "20"
},
"type": "phoneNumber",
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
},
{
"label": "Phone Number is most recent (hidden)",
"tooltip": "Select checkbox if phone number is most recent",
"hidden": true,
"tableView": false,
"defaultValue": true,
"key": "phoneNumberValidated",
"type": "checkbox",
"input": true,
"hideOnChildrenHidden": false
},
{
"label": "Effective From Date (hidden)",
"format": "yyyy-MM-dd",
"hidden": true,
"tableView": false,
"enableMinDateInput": false,
"datePicker": {
"disableWeekends": false,
"disableWeekdays": false
},
"enableMaxDateInput": false,
"enableTime": false,
"timePicker": {
"showMeridian": false
},
"key": "phoneNumberEffectiveFromDate",
"properties": {
"class": "start.date",
"fhirElement": "Patient.telecom.period.start"
},
"logic": [
{
"name": "Set Effective From Date to Today",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "phoneNumberValidated",
"eq": "true"
}
},
"actions": [
{
"name": "Set to Today",
"type": "value",
"value": "var d = moment().format('YYYY-MM-DD');\nvalue = d;"
}
]
},
{
"name": "Set Effective From Date to EMPI Date",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "phoneNumberValidated",
"eq": "false"
}
},
"actions": [
{
"name": "Set Date to EMPI Date",
"type": "value",
"value": "value = data.EMPIphoneNumberEffectiveFromDate"
}
]
}
],
"type": "datetime",
"input": true,
"widget": {
"type": "calendar",
"displayInTimezone": "viewer",
"locale": "en",
"useLocaleSettings": false,
"allowInput": true,
"mode": "single",
"enableTime": false,
"noCalendar": false,
"format": "yyyy-MM-dd",
"hourIncrement": 1,
"minuteIncrement": 1,
"time_24hr": true,
"minDate": null,
"disableWeekends": false,
"disableWeekdays": false,
"maxDate": null
},
"hideOnChildrenHidden": false
},
{
"label": "EMPI Effective From Date (hidden)",
"format": "yyyy-MM-dd",
"hidden": true,
"tableView": false,
"enableMinDateInput": false,
"datePicker": {
"disableWeekends": false,
"disableWeekdays": false
},
"enableMaxDateInput": false,
"enableTime": false,
"timePicker": {
"showMeridian": false
},
"key": "EMPIphoneNumberEffectiveFromDate",
"type": "datetime",
"input": true,
"widget": {
"type": "calendar",
"displayInTimezone": "viewer",
"locale": "en",
"useLocaleSettings": false,
"allowInput": true,
"mode": "single",
"enableTime": false,
"noCalendar": false,
"format": "yyyy-MM-dd",
"hourIncrement": 1,
"minuteIncrement": 1,
"time_24hr": true,
"minDate": null,
"disableWeekends": false,
"disableWeekdays": false,
"maxDate": null
},
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
},
{
"components": [
{
"label": "Email",
"tableView": true,
"key": "email",
"properties": {
"class": "email",
"fhirElement": "Patient.telecom.where(system='email').value"
},
"type": "email",
"input": true,
"hideOnChildrenHidden": false
},
{
"label": "Email Use",
"optionsLabelPosition": "right",
"inline": true,
"tableView": false,
"defaultValue": "home",
"values": [
{
"label": "Home",
"value": "home",
"shortcut": ""
},
{
"label": "Work",
"value": "work",
"shortcut": ""
},
{
"label": "Mobile",
"value": "mobile",
"shortcut": ""
}
],
"key": "patientEmailUse",
"properties": {
"class": "email.use",
"fhirElement": "Patient.telecom.where(system='email').use[0]"
},
"type": "radio",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
}
],
"key": "columns6",
"type": "columns",
"tableView": false,
"input": false
},
{
"html": "<p><strong>If BC PHN is unknown, a phone number AND address is required to align with provincial client identity standards.</strong></p>",
"label": "Content",
"refreshOnChange": false,
"key": "content1",
"type": "content",
"tableView": false,
"input": false,
"hideOnChildrenHidden": false
}
]
},
{
"label": "Address",
"key": "patientInformationAddress",
"properties": {
"formioResource": "addressV3",
"fhirElement": "Patient.address",
"fhirResource": "Address"
},
"type": "well",
"input": false,
"tableView": false,
"components": [
{
"html": "<p>Address</p>",
"label": "Content",
"refreshOnChange": false,
"key": "content2",
"type": "content",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Country",
"widget": "choicesjs",
"tableView": true,
"dataSrc": "url",
"defaultValue": "CA",
"data": {
"url": "https://test-phsaapiservices.azure-api.net/eforms/countries_iso.json",
"headers": [
{
"key": "",
"value": ""
}
]
},
"valueProperty": "value",
"selectThreshold": 0.3,
"key": "patientCountry",
"properties": {
"class": "country",
"fhirElement": "Address.country"
},
"type": "select",
"input": true,
"disableLimit": false,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "Province/Territory",
"widget": "choicesjs",
"tableView": true,
"dataSrc": "json",
"data": {
"json": [
{
"value": "BC",
"label": "British Columbia"
},
{
"value": "AB",
"label": "Alberta"
},
{
"value": "MB",
"label": "Manitoba"
},
{
"value": "NB",
"label": "New Brunswick"
},
{
"value": "NL",
"label": "Newfoundland"
},
{
"value": "NT",
"label": "Northwest Territories"
},
{
"value": "NS",
"label": "Nova Scotia"
},
{
"value": "NU",
"label": "Nunavut"
},
{
"value": "ON",
"label": "Ontario"
},
{
"value": "PE",
"label": "Prince Edward Island"
},
{
"value": "QC",
"label": "Quebec"
},
{
"value": "SK",
"label": "Saskatchewan"
},
{
"value": "YT",
"label": "Yukon"
}
]
},
"valueProperty": "value",
"selectThreshold": 0.3,
"customDefaultValue": "value=data.patientCountry.replace('CA', 'BC')",
"key": "patientProvince",
"properties": {
"class": "state",
"fhirElement": "Address.state"
},
"conditional": {
"show": true,
"when": "patientCountry",
"eq": "CA"
},
"logic": [
{
"name": "isCountryNotCanada",
"trigger": {
"type": "javascript",
"javascript": "result = (data['patientCountry'] !== \"CA\");"
},
"actions": [
{
"name": "nullifyProvince",
"type": "value",
"value": "value=''"
}
]
}
],
"type": "select",
"input": true,
"hideOnChildrenHidden": false
},
{
"label": "State",
"widget": "choicesjs",
"tableView": true,
"dataSrc": "json",
"data": {
"json": [
{
"value": "AL",
"label": "Alabama"
},
{
"value": "AK",
"label": "Alaska"
},
{
"value": "AZ",
"label": "Arizona"
},
{
"value": "AR",
"label": "Arkansas"
},
{
"value": "CA",
"label": "California"
},
{
"value": "CO",
"label": "Colorado"
},
{
"value": "CT",
"label": "Connecticut"
},
{
"value": "DE",
"label": "Delaware"
},
{
"value": "DC",
"label": "District of Columbia"
},
{
"value": "FL",
"label": "Florida"
},
{
"value": "GA",
"label": "Georgia"
},
{
"value": "HI",
"label": "Hawaii"
},
{
"value": "ID",
"label": "Idaho"
},
{
"value": "IL",
"label": "Illinois"
},
{
"value": "IN",
"label": "Indiana"
},
{
"value": "IA",
"label": "Iowa"
},
{
"value": "KS",
"label": "Kansas"
},
{
"value": "KY",
"label": "Kentucky"
},
{
"value": "LA",
"label": "Louisiana"
},
{
"value": "ME",
"label": "Maine"
},
{
"value": "MD",
"label": "Maryland"
},
{
"value": "MA",
"label": "Massachusetts"
},
{
"value": "MI",
"label": "Michigan"
},
{
"value": "MN",
"label": "Minnesota"
},
{
"value": "MS",
"label": "Mississippi"
},
{
"value": "MO",
"label": "Missouri"
},
{
"value": "MT",
"label": "Montana"
},
{
"value": "NE",
"label": "Nebraska"
},
{
"value": "NV",
"label": "Nevada"
},
{
"value": "NH",
"label": "New Hampshire"
},
{
"value": "NJ",
"label": "New Jersey"
},
{
"value": "NM",
"label": "New Mexico"
},
{
"value": "NY",
"label": "New York"
},
{
"value": "NC",
"label": "North Carolina"
},
{
"value": "ND",
"label": "North Dakota"
},
{
"value": "OH",
"label": "Ohio"
},
{
"value": "OK",
"label": "Oklahoma"
},
{
"value": "OR",
"label": "Oregon"
},
{
"value": "PA",
"label": "Pennsylvania"
},
{
"value": "RI",
"label": "Rhode Island"
},
{
"value": "SC",
"label": "South Carolina"
},
{
"value": "SD",
"label": "South Dakota"
},
{
"value": "Tn",
"label": "Tennessee"
},
{
"value": "TX",
"label": "Texas"
},
{
"value": "UT",
"label": "Utah"
},
{
"value": "VT",
"label": "Vermont"
},
{
"value": "VA",
"label": "Virginia"
},
{
"value": "WA",
"label": "Washington"
},
{
"value": "WV",
"label": "West Virginia"
},
{
"value": "WI",
"label": "Wisconsin"
},
{
"value": "WY",
"label": "Wyoming"
}
]
},
"valueProperty": "value",
"selectThreshold": 0.3,
"key": "patientState",
"properties": {
"class": "stateUS",
"fhirElement": "Address.state"
},
"conditional": {
"show": true,
"when": "patientCountry",
"eq": "US"
},
"logic": [
{
"name": "isCountryNotUS",
"trigger": {
"type": "javascript",
"javascript": "result = (data['patientCountry'] !== \"US\");"
},
"actions": [
{
"name": "nullifyState",
"type": "value",
"value": "value=''"
}
]
}
],
"type": "select",
"input": true,
"hideOnChildrenHidden": false
},
{
"label": "Province/State",
"tableView": true,
"key": "patientProvinceState",
"properties": {
"class": "stateFreeText",
"fhirElement": "Address.state"
},
"customConditional": "show = (data.patientCountry !== \"CA\" && data.patientCountry !== \"US\");",
"logic": [
{
"name": "isCountryCanadaUS",
"trigger": {
"type": "javascript",
"javascript": "result = (data['patientCountry'] == \"CA\" || data['patientCountry'] == \"US\");"
},
"actions": [
{
"name": "nullifypatientProvinceState",
"type": "value",
"value": "value=''"
}
]
}
],
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "City/Town",
"widget": "choicesjs",
"tableView": true,
"dataSrc": "url",
"data": {
"url": "https://test-phsaapiservices.azure-api.net/eforms/cities_in_bc_non_panorama.json",
"headers": [
{
"key": "",
"value": ""
}
]
},
"valueProperty": "label",
"selectThreshold": 0.3,
"key": "patientBCcity",
"properties": {
"class": "city",
"fhirElement": "Address.city"
},
"conditional": {
"show": true,
"when": "patientProvince",
"eq": "BC"
},
"logic": [
{
"name": "isProvinceNotBC",
"trigger": {
"type": "javascript",
"javascript": "result = data['patientProvince'] !== \"BC\";"
},
"actions": [
{
"name": "nullifyBCcity",
"type": "value",
"value": "value=''"
}
]
}
],
"type": "select",
"input": true,
"disableLimit": false,
"hideOnChildrenHidden": false
},
{
"label": "City/Town",
"tableView": true,
"key": "patientCityTown",
"properties": {
"class": "cityFreeText",
"fhirElement": "Address.city"
},
"conditional": {
"show": false,
"when": "patientProvince",
"eq": "BC"
},
"logic": [
{
"name": "isProvinceBC",
"trigger": {
"type": "javascript",
"javascript": "result = (data['patientProvince'] == \"BC\");"
},
"actions": [
{
"name": "nullifyNonBCcity",
"type": "value",
"value": "value=''"
}
]
}
],
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 4
}
],
"key": "columns8",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Address Use",
"optionsLabelPosition": "right",
"inline": true,
"tableView": false,
"values": [
{
"label": "Home",
"value": "home",
"shortcut": ""
},
{
"label": "Work",
"value": "work",
"shortcut": ""
},
{
"label": "Temporary",
"value": "temp",
"shortcut": ""
}
],
"key": "patientAddressUse",
"properties": {
"class": "address.use",
"fhirElement": "Address.use"
},
"type": "radio",
"input": true,
"hideOnChildrenHidden": false,
"defaultValue": "home"
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "Street Address Line",
"description": "Please confirm and update to most recent address",
"tableView": true,
"key": "patientStreetAddressLine1",
"properties": {
"class": "line1",
"fhirElement": "Address.line"
},
"type": "textfield",
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
},
{
"label": "Address is most recent (hidden)",
"tooltip": "Select checkbox if address is most recent",
"hidden": true,
"tableView": false,
"defaultValue": true,
"key": "addressValidated",
"properties": {
"questionnaireElement": "addressValidated"
},
"type": "checkbox",
"input": true,
"hideOnChildrenHidden": false
},
{
"label": "Effective From Date (hidden)",
"format": "yyyy-MM-dd",
"hidden": true,
"tableView": false,
"enableMinDateInput": false,
"datePicker": {
"disableWeekends": false,
"disableWeekdays": false
},
"enableMaxDateInput": false,
"enableTime": false,
"timePicker": {
"showMeridian": false
},
"key": "addressEffectiveFromDate",
"logic": [
{
"name": "Set Effective From Date to Today",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "addressValidated",
"eq": "true"
}
},
"actions": [
{
"name": "Set to Today",
"type": "value",
"value": "var d = moment().format('YYYY-MM-DD');\nvalue = d;"
}
]
},
{
"name": "Set Effective From Date to EMPI Date",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "addressValidated",
"eq": "false"
}
},
"actions": [
{
"name": "Set Date to EMPI Date",
"type": "value",
"value": "value = data.EMPIaddressEffectiveFromDate"
}
]
}
],
"type": "datetime",
"input": true,
"widget": {
"type": "calendar",
"displayInTimezone": "viewer",
"locale": "en",
"useLocaleSettings": false,
"allowInput": true,
"mode": "single",
"enableTime": false,
"noCalendar": false,
"format": "yyyy-MM-dd",
"hourIncrement": 1,
"minuteIncrement": 1,
"time_24hr": true,
"minDate": null,
"disableWeekends": false,
"disableWeekdays": false,
"maxDate": null
},
"hideOnChildrenHidden": false
},
{
"label": "EMPI Effective From Date (hidden)",
"format": "yyyy-MM-dd",
"hidden": true,
"tableView": false,
"enableMinDateInput": false,
"datePicker": {
"disableWeekends": false,
"disableWeekdays": false
},
"enableMaxDateInput": false,
"enableTime": false,
"timePicker": {
"showMeridian": false
},
"key": "EMPIaddressEffectiveFromDate",
"type": "datetime",
"input": true,
"widget": {
"type": "calendar",
"displayInTimezone": "viewer",
"locale": "en",
"useLocaleSettings": false,
"allowInput": true,
"mode": "single",
"enableTime": false,
"noCalendar": false,
"format": "yyyy-MM-dd",
"hourIncrement": 1,
"minuteIncrement": 1,
"time_24hr": true,
"minDate": null,
"disableWeekends": false,
"disableWeekdays": false,
"maxDate": null
},
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "Postal Code",
"description": "IMPORTANT: This is used to identify the client health region",
"inputMask": "A9A 9A9",
"tableView": true,
"case": "uppercase",
"key": "patientCanadianAddressPostalCode",
"properties": {
"class": "postalCode",
"fhirElement": "Address.postalCode"
},
"conditional": {
"show": true,
"when": "patientCountry",
"eq": "CA"
},
"logic": [
{
"name": "isCountryNotCA",
"trigger": {
"type": "javascript",
"javascript": "result = (data['patientCountry'] !== \"CA\");"
},
"actions": [
{
"name": "nullifyCApostalCode",
"type": "value",
"value": "value=''"
}
]
}
],
"type": "textfield",
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
},
{
"label": "Postal Code",
"tableView": true,
"case": "uppercase",
"key": "patientAddressPostalCode",
"properties": {
"class": "postalCodeFreeText",
"fhirElement": "Address.postalCode"
},
"conditional": {
"show": false,
"when": "patientCountry",
"eq": "CA"
},
"logic": [
{
"name": "isCountryCA",
"trigger": {
"type": "javascript",
"javascript": "result = (data['patientCountry'] == \"CA\");"
},
"actions": [
{
"name": "nullifyNonCApostalCode",
"type": "value",
"value": "value=''"
}
]
}
],
"type": "textfield",
"input": true,
"lockKey": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 4
}
],
"key": "columns9",
"type": "columns",
"input": false,
"tableView": false
}
]
},
{
"label": "COVID19 Imms History",
"key": "covid19ImmsHistory",
"type": "well",
"input": false,
"tableView": false,
"components": [
{
"label": "encodedHistoricImmz",
"hidden": true,
"tableView": true,
"clearOnHide": false,
"key": "encodedHistoricImmz",
"properties": {
"fhirElement": "Patient.photo.data"
},
"type": "textfield",
"input": true
},
{
"label": "COVID-19 Immunization History",
"autoExpand": false,
"tableView": true,
"defaultValue": "Client Not Found. Please use Client Search or refine your search and try again by re-launching the eForm. If you receive this message again then there is no Immunization history retrievable for this client at this time.",
"persistent": "client-only",
"key": "covid19ImmunizationHistory1",
"logic": [
{
"name": "IMMSHISTORYPOPULATED",
"trigger": {
"type": "javascript",
"javascript": "result=(data['encodedHistoricImmz'].length > 0)"
},
"actions": [
{
"name": "DECODEIMMSHISTORY",
"type": "value",
"value": "value=window.atob(data.encodedHistoricImmz)"
}
]
},
{
"name": "IMMSHISTORYNULL",
"trigger": {
"type": "javascript",
"javascript": "result=(!data['encodedHistoricImmz'])"
},
"actions": [
{
"name": "DEFAULT",
"type": "value",
"value": "value='Client Not Found. Please use Client Search or refine your search and try again by re-launching the eForm. If you receive this message again then there is no Immunization history retrievable for this client at this time.'"
}
]
}
],
"type": "textarea",
"rows": 7,
"input": true
}
]
}
]
},
{
"title": "Client Consent Readiness",
"collapsible": false,
"key": "consentReadiness",
"properties": {
"formioResource": "consent",
"fhirResource": "consent"
},
"type": "panel",
"label": "Client Consent Readiness",
"input": false,
"tableView": false,
"components": [
{
"label": "Consent Readiness",
"key": "consentReadiness1",
"type": "well",
"input": false,
"tableView": false,
"components": [
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Informed Consent for Series Obtained From:",
"optionsLabelPosition": "right",
"inline": true,
"tableView": false,
"values": [
{
"label": "Client",
"value": "C",
"shortcut": ""
},
{
"label": "Client (Mature Minor)",
"value": "MM",
"shortcut": ""
},
{
"label": "Substitute Decision Maker",
"value": "SUBDECISIONMAKER",
"shortcut": ""
}
],
"key": "consentGivenBy",
"properties": {
"class": "consentGivenBy",
"fhirElement": "consent.performer.relatedPerson.relationship.code",
"settings": "coding"
},
"type": "radio",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 6,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 6
},
{
"components": [
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
}
],
"key": "columns12",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Last Name of Person Giving Consent",
"tableView": true,
"clearOnHide": false,
"key": "personGivingConsentLastName",
"properties": {
"class": "personGivingConsentLastName",
"fhirElement": "consent.performer.relatedPerson.name.family."
},
"conditional": {
"show": true,
"when": "consentGivenBy",
"eq": "SUBDECISIONMAKER"
},
"logic": [
{
"name": "DefaultValueIfCLIENT",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "C"
}
},
"actions": [
{
"name": "DefaultValueToClientLastName",
"type": "value",
"value": "value=data.patientNameFamily"
}
]
},
{
"name": "DefaultValueIfMatureMinor",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "MM"
}
},
"actions": [
{
"name": "DefaultValueClientLastName",
"type": "value",
"value": "value=data.patientNameFamily"
}
]
}
],
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "First Name of Person Giving Consent",
"tableView": true,
"clearOnHide": false,
"key": "personGivingConsentFirstName",
"properties": {
"class": "personGivingConsentFirstName",
"fhirElement": "consent.performer.relatedPerson.name.given"
},
"conditional": {
"show": true,
"when": "consentGivenBy",
"eq": "SUBDECISIONMAKER"
},
"logic": [
{
"name": "DefaultValueIfCLIENT",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "C"
}
},
"actions": [
{
"name": "DefaultValueClientFirstName",
"type": "value",
"value": "value=data.patientNameGiven"
}
]
},
{
"name": "DefaultValueIfMATUREMINOR",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "MM"
}
},
"actions": [
{
"name": "DefaultValueClientFirstName",
"type": "value",
"value": "value=data.patientNameGiven"
}
]
}
],
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "Form of Consent",
"widget": "choicesjs",
"tableView": true,
"dataSrc": "json",
"data": {
"json": [
{
"label": "In Person",
"value": "INPERSON"
},
{
"label": "Telephone",
"value": "PHONE1"
},
{
"label": "Written",
"value": "W"
}
]
},
"valueProperty": "label",
"dataType": "string",
"selectThreshold": 0.3,
"key": "formOfConsent",
"conditional": {
"show": true,
"when": "consentGivenBy",
"eq": "SUBDECISIONMAKER"
},
"type": "select",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 4
}
],
"key": "columns13",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Consent Comment (hidden)",
"autoExpand": false,
"hidden": true,
"tableView": true,
"clearOnHide": false,
"key": "consentComment",
"properties": {
"class": "consentComment",
"fhirElement": "consent.extension.comment"
},
"logic": [
{
"name": "Consent Given By Client",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "C"
}
},
"actions": [
{
"name": "Concatenate",
"type": "value",
"value": "value = \"Form of Consent: In Person\""
}
]
},
{
"name": "Consent Not Obtained",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": ""
}
},
"actions": [
{
"name": "No Concatenate",
"type": "value",
"value": "value = \"\""
}
]
},
{
"name": "Consent Given By Minor",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "MM"
}
},
"actions": [
{
"name": "Concatenate",
"type": "value",
"value": "value = \"Form of Consent: In Person\""
}
]
},
{
"name": "Consent Given By Sub",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "SUBDECISIONMAKER"
}
},
"actions": [
{
"name": "Concatenate",
"type": "value",
"value": " if (data.formOfConsent) {\r\n value = \"Form of Consent: \" + data.formOfConsent;\r\n } else {\r\n value = \"Form of Consent: Not Specified\";\r\n }"
}
]
}
],
"type": "textarea",
"input": true,
"hideOnChildrenHidden": false
}
]
}
]
},
{
"title": "COVID-19 Immunization Data",
"collapsible": false,
"key": "covid19ImmunizationHistory",
"type": "panel",
"label": "COVID-19 Immunization Data",
"input": false,
"tableView": false,
"components": [
{
"label": "Provider Info",
"key": "providerInfo",
"properties": {
"formioResource": "providerInformation",
"fhirResource": "Practitioner"
},
"type": "well",
"input": false,
"tableView": false,
"components": [
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Provider Last Name",
"tableView": true,
"validate": {
"required": true
},
"key": "providerLastName",
"properties": {
"class": "last.name",
"fhirElement": "Practitioner.name.family"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "Provider First Name",
"tableView": true,
"validate": {
"required": true
},
"key": "providerFirstName",
"properties": {
"class": "first.name",
"fhirElement": "Practitioner.name.given"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
],
"size": "md",
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 4
}
],
"key": "columns2",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Provider ID Type (hidden)",
"optionsLabelPosition": "right",
"inline": false,
"hidden": true,
"tableView": false,
"values": [
{
"label": "CPSID - Physicians",
"value": "urn:CPSID",
"shortcut": ""
},
{
"label": "MSP Practitioner Number",
"value": "urn:MPID",
"shortcut": ""
},
{
"label": "PHID - Pharmacists",
"value": "urn:PHID",
"shortcut": ""
},
{
"label": "RNID - Registered Nurses",
"value": "urn:RNID",
"shortcut": ""
}
],
"key": "providerIdType",
"properties": {
"class": "identifier.type",
"fhirElement": "Practitioner.identifier.system"
},
"type": "radio",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "Provider Role (hidden)",
"optionsLabelPosition": "right",
"inline": false,
"hidden": true,
"tableView": false,
"values": [
{
"label": "Nurse - Registered",
"value": "RN",
"shortcut": ""
},
{
"label": "Pharmacist",
"value": "PHARM",
"shortcut": ""
},
{
"label": "Physician",
"value": "MD",
"shortcut": ""
}
],
"key": "providerRole",
"properties": {
"class": "role",
"fhirElement": "Practitioner.name.suffix"
},
"type": "radio",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 4
},
{
"components": [
{
"label": "Provider ID (hidden)",
"hidden": true,
"tableView": true,
"key": "providerId",
"properties": {
"class": "provider.identifier",
"fhirElement": "Practitioner.identifier.value"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 4,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 4
}
],
"key": "columns",
"type": "columns",
"input": false,
"tableView": false
}
]
},
{
"label": "COVID19ImmsData",
"key": "covid19ImmsData",
"properties": {
"formioResource": "immunization",
"fhirResource": "Immunization"
},
"type": "well",
"input": false,
"tableView": false,
"components": [
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Reason for Immunization",
"widget": "choicesjs",
"tooltip": "Z_C19 Essential Visitor to LTC / Assisted Living: People identified as essential visitors to residents of Long Term Care (LTC) and Assisted Living (AL) facilities\r\nZ_C19 Home Care Recipient: Clients receiving home care\r\nZ_C19 Homeless or Lives in Shelter: Clients who experience homelessness or who live a shelter\r\nZ_C19 Pandemic Priority Population: Includes any person who does not qualify under any other reason. For example staff working in shelters, Indigenous peoples and age-based eligibility\r\nZ_C19 Paramedic/First Responder: Staff who are Paramedics or first responders\r\nZ_C19 Physician: Community physicians and medical specialists\r\nZ_C19 Resident - Assisted Living: Residents who live in an Assisted Living facility\r\nZ_C19 Resident - Awaiting LTC or AL Placement: Residents who have been assessed and are waiting for placement in LTC or Assisted Living\r\nZ_C19 Resident - Congregate Settings: Residents who live in congregate settings such as correctional facilities, group homes, mental health residential\r\nZ_C19 Resident - Long Term Care: Residents who live in a Long Term Care facility\r\nZ_C19 Staff - Assisted Living: Staff who work in an Assisted Living facility\r\nZ_C19 Staff - Community: Staff who provide services in community setting \r\nZ_C19 Staff - Hospital: Staff who work in a hospital\r\nZ_C19 Staff - Long Term Care: Staff who work in a Long Term Care facility (private or public)\r\nZ_C19 Staff - Pandemic Support: Staff who support the pandemic response who don't work in a health care setting",
"tableView": true,
"dataSrc": "json",
"data": {
"json": [
{
"label": "Z_C19 Resident - Assisted Living",
"value": "IMMSREASON_C19_RESIDENT_AL"
},
{
"label": "Z_C19 Staff - Assisted Living",
"value": "IMMSREASON_C19_STAFF_AL"
},
{
"label": "Z_C19 Resident - Long Term Care",
"value": "IMMSREASON_C19_RESIDENT_LTC"
},
{
"label": "Z_C19 Staff - Long Term Care",
"value": "IMMSREASON_C19_STAFF_LTC"
},
{
"label": "Z_C19 Resident - Awaiting LTC or AL Placement",
"value": "IMMSREASON_C19_RESIDENT_ASSAWA_LTC_AL_ACUTE"
},
{
"label": "Z_C19 Resident - Congregate Settings",
"value": "IMMSREASON_C19_RESIDENT_CONGREGATESETTINGS"
},
{
"label": "Z_C19 Staff - Congregate Settings",
"value": "IMMSREASON_C19_STAFF_CONGREGATE_SETTINGS"
},
{
"label": "Z_C19 Resident - Independent Living",
"value": "IMMSREASON_C19_RES_INDEPENDENT_LIVING"
},
{
"label": "Z_C19 Staff - Independent Living",
"value": "IMMSREASON_C19_STAFF_INDEPENDENT_LIVING"
},
{
"label": "Z_C19 Staff - Community",
"value": "IMMSREASON_C19_STAFF_COMMUNITY"
},
{
"label": "Z_C19 Staff - Hospital",
"value": "IMMSREASON_C19_STAFF_HOSPITAL"
},
{
"label": "Z_C19 Staff - Pandemic Support",
"value": "IMMSREASON_C19_PANDEMIC_SUPPORT"
},
{
"label": "Z_C19 Essential Visitor to LTC / Assisted Living",
"value": "IMMSREASON_C19_ESSVISTOLTC"
},
{
"label": "Z_C19 Home Care Recipient",
"value": "IMMSREASON_C19_HOMECARE_RECIPIENT"
},
{
"label": "Z_C19 Homeless or Lives in Shelter",
"value": "IMMSREASON_C19_HOMELESSSHELTER"
},
{
"label": "Z_C19 Pandemic Priority Population",
"value": "IMMSREASON_C19_PANDEMICPRIORITYPOP"
},
{
"label": "Z_C19 Paramedic/First Responder",
"value": "IMMSREASON_C19_PARAMEDIC"
},
{
"label": "Z_C19 Physician",
"value": "IMMSREASON_C19_PHYSICIAN"
}
]
},
"valueProperty": "value",
"selectThreshold": 0.3,
"validate": {
"required": true
},
"key": "reasonForImmunization",
"properties": {
"class": "reasonCode",
"fhirElement": "Immunization.reasonCode.code",
"settings": "coding"
},
"type": "select",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 6,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 6
},
{
"components": [
{
"label": "Staff Worksite/Client’s Facility",
"widget": "choicesjs",
"description": "Enter facility only if client works or lives in Long Term Care or Assisted Living. If client works at multiple facilities, select the facility provided by the client and enter additional facilities in comment.",
"tableView": true,
"dataSrc": "url",
"data": {
"url": "https://api.eforms.phsaehealth.ca/client_facilities.json",
"headers": [
{
"key": "",
"value": ""
}
]
},
"valueProperty": "value",
"selectThreshold": 0.3,
"customOptions": {
"searchResultLimit": 7
},
"key": "clientFacility",
"properties": {
"class": "staffClient.facility",
"questionnaireElement": "clientFacility"
},
"logic": [
{
"name": "Mandatory for LTC Staff",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "reasonForImmunization",
"eq": "IMMSREASON_C19_STAFF_LTC"
}
},
"actions": [
{
"name": "Set Required",
"type": "property",
"property": {
"label": "Required",
"value": "validate.required",
"type": "boolean"
},
"state": true
}
]
},
{
"name": "Mandatory for LTC Resident",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "reasonForImmunization",
"eq": "IMMSREASON_C19_RESIDENT_LTC"
}
},
"actions": [
{
"name": "Set Required",
"type": "property",
"property": {
"label": "Required",
"value": "validate.required",
"type": "boolean"
},
"state": true
}
]
},
{
"name": "Mandatory for AL Staff",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "reasonForImmunization",
"eq": "IMMSREASON_C19_STAFF_AL"
}
},
"actions": [
{
"name": "Set Required",
"type": "property",
"property": {
"label": "Required",
"value": "validate.required",
"type": "boolean"
},
"state": true
}
]
},
{
"name": "Mandatory for AL Resident",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "reasonForImmunization",
"eq": "IMMSREASON_C19_RESIDENT_AL"
}
},
"actions": [
{
"name": "Set Required",
"type": "property",
"property": {
"label": "Required",
"value": "validate.required",
"type": "boolean"
},
"state": true
}
]
}
],
"type": "select",
"input": true,
"hideOnChildrenHidden": false,
"disableLimit": false
}
],
"width": 6,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 6
}
],
"key": "columns10",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Agent",
"widget": "choicesjs",
"tableView": true,
"defaultValue": 1119349007,
"data": {
"values": [
{
"label": "COVID-19 mRNA",
"value": "1119349007"
},
{
"label": "COVID-19 AZ Test",
"value": "covid19AzTest"
}
]
},
"selectThreshold": 0.3,
"validate": {
"required": true
},
"key": "agent",
"properties": {
"class": "vaccineCode",
"fhirElement": "Immunization.vaccineCode.code",
"settings": "coding"
},
"type": "select",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "Date Administered",
"widget": {
"type": "calendar",
"altInput": true,
"allowInput": true,
"clickOpens": true,
"enableDate": true,
"enableTime": false,
"mode": "single",
"noCalendar": false,
"format": "yyyy-MM-dd",
"dateFormat": "yyyy-MM-dd",
"useLocaleSettings": false,
"hourIncrement": 1,
"minuteIncrement": 5,
"time_24hr": false,
"saveAs": "date",
"maxDate": "moment()",
"locale": "en"
},
"tableView": true,
"customDefaultValue": "var d = moment().format('YYYY-MM-DD');\nvalue = d;",
"validate": {
"required": true
},
"key": "dateAdministered",
"properties": {
"class": "vaccination.date",
"fhirElement": "Immunization.occurrenceDateTime"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
],
"size": "md",
"width": 6,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 6
}
],
"key": "columns1",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Lot Number",
"widget": "choicesjs",
"tableView": true,
"dataSrc": "url",
"data": {
"url": "https://www.eforms.phsaehealth.ca/vpp-smart/inventory.json",
"headers": [
{
"key": "",
"value": ""
}
]
},
"valueProperty": "value",
"selectThreshold": 0.3,
"validate": {
"required": true
},
"key": "lotNumberInventory",
"type": "select",
"input": true,
"hideOnChildrenHidden": false,
"disableLimit": false
},
{
"label": "extractedLotNumber(hidden)",
"hidden": true,
"tableView": true,
"clearOnHide": false,
"calculateValue": "value = data.lotNumberInventory.split(\"|\")[0]",
"key": "lotNumber",
"properties": {
"class": "lotNumber",
"fhirElement": "Immunization.lotNumber",
"settings": "coding"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "Lot Number Expiry Date",
"widget": {
"type": "calendar",
"altInput": true,
"allowInput": true,
"clickOpens": true,
"enableDate": true,
"enableTime": false,
"mode": "single",
"noCalendar": false,
"format": "yyyy-MM-dd",
"dateFormat": "yyyy-MM-dd",
"useLocaleSettings": false,
"hourIncrement": 1,
"minuteIncrement": 5,
"time_24hr": false,
"saveAs": "date",
"locale": "en"
},
"disabled": true,
"tableView": true,
"calculateValue": "value = data.lotNumberInventory.split(\"|\")[1]",
"key": "lotNumberExpiryDate",
"properties": {
"class": "expirationDate",
"fhirElement": "Immunization.expirationDate"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "Dosage",
"tableView": true,
"redrawOn": "lotNumber",
"calculateValue": "value = data.lotNumberInventory.split(\"|\")[2]",
"allowCalculateOverride": true,
"key": "dosage",
"properties": {
"class": "dosage",
"fhirElement": "Immunization.doseQuantity.value"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
},
{
"components": [
{
"label": "Dosage UOM",
"widget": "choicesjs",
"disabled": true,
"tableView": true,
"selectThreshold": 0.3,
"calculateValue": "value = data.lotNumberInventory.split(\"|\")[3]",
"key": "dosageUom",
"properties": {
"class": "dosageQuantity.unit",
"fhirElement": "Immunization.doseQuantity.unit",
"settings": "coding"
},
"type": "select",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
}
],
"key": "columns3",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
{
"label": "Site",
"widget": "choicesjs",
"tableView": true,
"data": {
"values": [
{
"label": "Arm - Left",
"value": "368208006"
},
{
"label": "Arm - Left deltoid",
"value": "16217701000119102"
},
{
"label": "Arm - Right",
"value": "368209003"
},
{
"label": "Arm - Right deltoid",
"value": "16217661000119109"
},
{
"label": "Buttock",
"value": "46862004"
},
{
"label": "Buttock - Left",
"value": "723979003"
},
{
"label": "Buttock - Left dorsogluteal",
"value": "LGD"
},
{
"label": "Buttock - Left ventrogluteal",
"value": "LVG"
},
{
"label": "Buttock - Right",
"value": "723980000"
},
{
"label": "Buttock - Right dorsogluteal",
"value": "RDG"
},
{
"label": "Buttock - Right ventrogluteal",
"value": "RVG"
},
{
"label": "Leg - Left",
"value": "48979004"
},
{
"label": "Leg - Right",
"value": "32696007"
}
]
},
"selectThreshold": 0.3,
"validate": {
"required": true
},
"key": "site",
"properties": {
"class": "site",
"fhirElement": "Immunization.site.code",
"settings": "coding"
},
"type": "select",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "Route",
"widget": "choicesjs",
"tableView": true,
"data": {
"values": [
{
"label": "Infiltrate",
"value": "718329006"
},
{
"label": "Intradermal",
"value": "372464004"
},
{
"label": "Intramuscular",
"value": "78421000"
},
{
"label": "Intranasal",
"value": "46713006"
},
{
"label": "Intravenous",
"value": "47625008"
},
{
"label": "Oral",
"value": "26643006"
},
{
"label": "Subcutaneous",
"value": "34206005"
}
]
},
"selectThreshold": 0.3,
"calculateValue": "value = data.lotNumberInventory.split(\"|\")[4]",
"validate": {
"required": true
},
"key": "route",
"properties": {
"class": "route",
"fhirElement": "Immunization.route.code",
"settings": "coding"
},
"type": "select",
"input": true,
"hideOnChildrenHidden": false
}
],
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 3
},
{
"components": [
{
"label": "Trade Name",
"disabled": true,
"tableView": true,
"redrawOn": "lotNumber",
"calculateValue": "value = data.lotNumberInventory.split(\"|\")[6]",
"key": "tradeName",
"properties": {
"class": "tradeName",
"key": "http://loinc.org"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
},
{
"components": [
{
"label": "Manufacturer",
"disabled": true,
"tableView": true,
"redrawOn": "lotNumber",
"calculateValue": "value = data.lotNumberInventory.split(\"|\")[7]",
"key": "manufacturer",
"properties": {
"class": "manufacturer"
},
"type": "textfield",
"input": true,
"hideOnChildrenHidden": false
}
],
"size": "md",
"width": 3,
"offset": 0,
"push": 0,
"pull": 0,
"currentWidth": 3
}
],
"key": "columns4",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Columns",
"columns": [
{
"components": [
],
"width": 6,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 6
},
{
"components": [
],
"width": 6,
"offset": 0,
"push": 0,
"pull": 0,
"size": "md",
"currentWidth": 6
}
],
"key": "columns5",
"type": "columns",
"input": false,
"tableView": false
},
{
"label": "Comment",
"autoExpand": false,
"tableView": true,
"key": "userComment",
"type": "textarea",
"input": true
},
{
"label": "Final Comment to Send (hidden)",
"autoExpand": false,
"hidden": true,
"tableView": true,
"clearOnHide": false,
"key": "comment",
"properties": {
"class": "note",
"fhirElement": "Immunization.note"
},
"logic": [
{
"name": "Consent Given By Client",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "C"
}
},
"actions": [
{
"name": "Concatenate",
"type": "value",
"value": "value = data.userComment + \" Consent Readiness: Consent Given By Client\""
}
]
},
{
"name": "Consent Not Obtained",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": ""
}
},
"actions": [
{
"name": "No Concatenate",
"type": "value",
"value": "value = data.userComment"
}
]
},
{
"name": "Consent Given By Minor",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "MM"
}
},
"actions": [
{
"name": "Concatenate",
"type": "value",
"value": "value = data.userComment + \" Consent Readiness: Consent Given By Client (Mature Minor)\""
}
]
},
{
"name": "Consent Given By Sub",
"trigger": {
"type": "simple",
"simple": {
"show": true,
"when": "consentGivenBy",
"eq": "SUBDECISIONMAKER"
}
},
"actions": [
{
"name": "Concatenate",
"type": "value",
"value": "if (data.personGivingConsentLastName || data.personGivingConsentFirstName) {\r\n if (data.formOfConsent) {\r\n value = data.userComment + \" Consent Readiness: Consent Given By Substitute Decision Maker\" + \" Name: \" + data.personGivingConsentFirstName + \" \" + data.personGivingConsentLastName + \" Form of Consent: \" + data.formOfConsent;\r\n } else {\r\n value = data.userComment + \" Consent Readiness: Consent Given By Substitute Decision Maker\" + \" Name: \" + data.personGivingConsentFirstName + \" \" + data.personGivingConsentLastName + \" Form of Consent: Not Specified\";\r\n }\r\n} else {\r\n if (data.formOfConsent) {\r\n value = data.userComment + \" Consent Readiness: Consent Given By Substitute Decision Maker\" + \" Name: Not Specified\" + \" Form of Consent: \" + data.formOfConsent;\r\n } else {\r\n value = data.userComment + \" Consent Readiness: Consent Given By Substitute Decision Maker\" + \" Name: Not Specified\" + \" Form of Consent: Not Specified\";\r\n }\r\n}"
}
]
}
],
"type": "textarea",
"input": true
}
],
"hideOnChildrenHidden": false
},
{
"html": "<p style=\"text-align:center;\"><span class=\"text-small\">COVID-19 Immunization Entry Form V1.7</span></p>",
"label": "Content",
"refreshOnChange": false,
"key": "content3",
"type": "content",
"input": false,
"tableView": false
}
]
},
{
"label": "Submit",
"showValidations": false,
"tableView": false,
"key": "submit",
"type": "button",
"input": true
}
], "revisions": "", "_vid": 0, "title": "EK-test-C19ImmzForm", "display": "form", "access": [ { "roles": [
],
"type": "create_own"
},
{
"roles": [
],
"type": "create_all"
},
{
"roles": [
],
"type": "read_own"
},
{
"roles": [
"5d7a912e7e841ebcf4eec846",
"5d7a912e7e841e0cb3eec847",
"5d7a912e7e841e3e80eec848",
"5d7a912e7e841e629eeec849",
"5d7a912e7e841e3eabeec84a",
"5d7a912e7e841eb439eec84b",
"60df51745f0f605884fad49c"
],
"type": "read_all"
},
{
"roles": [
],
"type": "update_own"
},
{
"roles": [
],
"type": "update_all"
},
{
"roles": [
],
"type": "delete_own"
},
{
"roles": [
],
"type": "delete_all"
},
{
"roles": [
],
"type": "team_read"
},
{
"roles": [
],
"type": "team_write"
},
{
"roles": [
],
"type": "team_admin"
}
], "submissionAccess": [ { "roles": [ "5d7a912e7e841e3e80eec848" ], "type": "create_own" }, { "roles": [
],
"type": "create_all"
},
{
"roles": [
],
"type": "read_own"
},
{
"roles": [
],
"type": "read_all"
},
{
"roles": [
],
"type": "update_own"
},
{
"roles": [
],
"type": "update_all"
},
{
"roles": [
],
"type": "delete_own"
},
{
"roles": [
],
"type": "delete_all"
},
{
"roles": [
],
"type": "team_read"
},
{
"roles": [
],
"type": "team_write"
},
{
"roles": [
],
"type": "team_admin"
}
], "controller": "", "properties": { "httpResponse200": "Submission is successful. If there is any concern or question about the information submitted, someone may contact you." }, "settings": { "logs": "true" }, "name": "ekTestC19ImmzForm", "path": "ektestc19immzform", "project": "5d7a912e7e841ec64eeec845", "created": "2021-07-05T23:04:57.057Z", "modified": "2021-07-17T17:38:42.494Z", "machineName": "sandbox-phsaformrepository:ekTestC19ImmzForm" }