PR1411202212269605 Mlife COVIDDetails Reflexive Data

[{"1":[]},{"1":"\n\n\t\t\t\t\t\t\t\t\t\n\n\t\t\t\t\t\t\t\t\t\n\n\t\t\t\t\t\t\t\t\t\
n\n\t\t\t\t\t\t\t\t\t\n\n\t\t\t\t\t\t\t\t\t\n\n\t\t\t\t\t\t\t\t\t<div class=\"row
m-0 p-0 mt-2 mt-sm-2\" id=\"1,80\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3
pr-sm-3\">1</div><div class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-
align:justify\">Are you, or your family have you been in close contact with anyone
who has been quarantined or who has been diagnosed with novel coronavirus (SARS-
CoV-2/COVID-19) ?</div><div class=\"col-sm-3 p-0 col-12\"><ul class=\"mb-0 mb-sm-1
text-right\" style=\"padding-left: 0px;\"><li style=\"display: inline-block;
margin-left: 0px; margin-bottom: 5px; margin-top: 5px;\"><input type=\"radio\"
name=\"80,80,mlife,COVIDDetails\" id=\"80,80,0,mlife,COVIDDetails\" value=\"Yes\"
class=\"radioNormal\" validate_this=\"true\" v_is_mandatory=\"true\"
validation_msg=\"Please select an answer for Q.1.\" validate_sub_quid=\"true\"
v_sub_quid=\"801\" v_mandatory_type=\"fill-all\" mandatory_msg=\"Please select an
answer for Q.1.a\" disabled=\"\"><label style=\"margin-left: 5px;margin-right:
10px;\" for=\"80,80,0,mlife,COVIDDetails\" class=\"
css-labelq\">Yes</label></li><li style=\"display: inline-block; margin-left: 0px;
margin-bottom: 5px; margin-top: 5px;\"><input type=\"radio\"
name=\"80,80,mlife,COVIDDetails\" id=\"80,80,1,mlife,COVIDDetails\" value=\"No\"
validation_msg=\"Please select an answer for Q.1.\" checked=\"true\"
disabled=\"\"><label style=\"margin-left: 5px;margin-right: 10px;\"
for=\"80,80,1,mlife,COVIDDetails\" class=\"
css-labelq\">No</label></li></ul></div></div><div class=\"row m-0 p-0 mt-2 mt-sm-
2\" id=\"1,81\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-3\">2</div><div
class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-align:justify\">Are you, or
your family ever been serving a notice of quarantine in any form imposed by local
health authorities or government or airport authority for possible exposure to
novel coronavirus (SARS- CoV2/COVID-19)?</div><div class=\"col-sm-3 p-0 col-
12\"><ul class=\"mb-0 mb-sm-1 text-right\" style=\"padding-left: 0px;\"><li
style=\"display: inline-block; margin-left: 0px; margin-bottom: 5px; margin-top:
5px;\"><input type=\"radio\" name=\"81,81,mlife,COVIDDetails\"
id=\"81,81,0,mlife,COVIDDetails\" value=\"Yes\" class=\"radioNormal\"
validate_this=\"true\" v_is_mandatory=\"true\" validation_msg=\"Please select an
answer for Q.2.\" validate_sub_quid=\"true\" v_sub_quid=\"813,812,811,815,814\"
v_mandatory_type=\"fill-all\" mandatory_msg=\"Please select an answer for Q.2.\"
for=\"81,81,0,mlife,COVIDDetails\" class=\" css-labelq\">Yes</label></li><li
id=\"81,81,1,mlife,COVIDDetails\" value=\"No\" class=\"radioNormal\"
answer for Q.2.\" checked=\"true\" disabled=\"\"><label style=\"margin-left:
5px;margin-right: 10px;\" for=\"81,81,1,mlife,COVIDDetails\" class=\" css-
labelq\">No</label></li></ul></div></div><div class=\"row m-0 p-0 mt-2 mt-sm-2\"
id=\"1,83\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-3\">3</div><div
class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-align:justify\">Have you
been advised to be tested to rule in, or rule out, a diagnosis of novel coronavirus
(SARSCoV-2/COVID-19)? Or, are you awaiting the result of a test which has already
been submitted for the novel coronavirus (SARS-CoV-2/COVID-19)?</div><div
class=\"col-sm-3 p-0 col-12\"><ul class=\"mb-0 mb-sm-1 text-right\"
style=\"padding-left: 0px;\"><li style=\"display: inline-block; margin-left: 0px;
answer for Q.3.\" disabled=\"\"><label style=\"margin-left: 5px;margin-right:
ever tested positive for the novel coronavirus (SARS-CoV-2/COVID-19)?</div><div
v_sub_quid=\"842,841\" v_mandatory_type=\"fill-all\" mandatory_msg=\"Please select
an answer for Q.4.A\" disabled=\"\"><label style=\"margin-left: 5px;margin-right:
experienced any of the following symptoms within the last 14 days? • Any fever /
Cough / Shortness of breath • Malaise (flu-like tiredness) / Rhinorrhea (mucus
discharge from the nose) • Sore throat • Gastro-intestinal symptoms such as nausea,
vomiting and/or diarrhea</div><div class=\"col-sm-3 p-0 col-12\"><ul class=\"mb-0
mb-sm-1 text-right\" style=\"padding-left: 0px;\"><li style=\"display: inline-
block; margin-left: 0px; margin-bottom: 5px; margin-top: 5px;\"><input
type=\"radio\" name=\"85,85,mlife,COVIDDetails\" id=\"85,85,0,mlife,COVIDDetails\"
value=\"Yes\" class=\"radioNormal\" validate_this=\"true\" v_is_mandatory=\"true\"
class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-align:justify\">Are you a
Healthcare professionals (Include for instance General Practitioners, Doctors,
Hospital Doctors, Surgeons, Therapists, Nurses, Pathologist, paramedics,
Pharmacist, Ward helpers, Individuals) working in Hospitals/ Clinics having novel
coronavirus (SARS-CoV-2/COVID-19) Ward ?</div><div class=\"col-sm-3 p-0 col-
12\"><ul class=\"mb-0 mb-sm-1 text-right\" style=\"padding-left: 0px;\"><li
answer for Q.6.\" validate_sub_quid=\"true\" v_sub_quid=\"861\"
v_mandatory_type=\"fill-all\" mandatory_msg=\"Please select an answer for Q.6.\"
answer for Q.6.\" checked=\"true\" disabled=\"\"><label style=\"margin-left:
labelq\">No</label></li></ul></div></div><div class=\"row m-0 p-0 mt-2 mt-sm-2\"
id=\"1,87\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-3\">7</div><div
class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-align:justify\">Travel
Declaration</div><div class=\"col-sm-3
p-0 col-12\" style=\"display: none;\"><ul class=\"mb-0 mb-sm-1 text-right\"
set_checked=\"true\" class=\"radioNormal\" validation_msg=\"Please select an answer
for Q.7.\" checked=\"true\" disabled=\"\"><label style=\"margin-left: 5px;margin-
right: 10px;\" for=\"87,87,0,mlife,COVIDDetails\" class=\"
class=\"radioNormal\" validation_msg=\"Please select an answer for Q.7.\"
2\" id=\"1,871\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3
pr-sm-3\">A</div><div class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-
align:justify\">Are you currently residing outside of Sri Lanka?</div><div
name=\"871,871,mlife,COVIDDetails\" id=\"871,871,0,mlife,COVIDDetails\"
validation_msg=\"Please select an answer for Q.7.A\" validate_sub_quid=\"true\"
v_sub_quid=\"8714,8713,8712,8711\" v_mandatory_type=\"fill-all\"
mandatory_msg=\"Please select an answer for Q.7.A\" disabled=\"\"><label
style=\"margin-left: 5px;margin-right: 10px;\" for=\"871,871,0,mlife,COVIDDetails\"
class=\" css-labelq\">Yes</label></li><li style=\"display: inline-block; margin-
left: 0px; margin-bottom: 5px; margin-top: 5px;\"><input type=\"radio\"
value=\"No\" class=\"radioNormal\" validate_this=\"true\" v_is_mandatory=\"true\"
validation_msg=\"Please select an answer for Q.7.A\" checked=\"true\"
pr-sm-3\">B</div><div class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-
align:justify\">Have you travelled abroad in the past 14 days?</div><div
validation_msg=\"Please select an answer for Q.7.B\" validate_sub_quid=\"true\"
mandatory_msg=\"Please select an answer for Q.7.B\" disabled=\"\"><label
validation_msg=\"Please select an answer for Q.7.B\" checked=\"true\"
pr-sm-3\">C</div><div class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-
align:justify\">Do you intend to travel abroad in next 3 months?</div><div
validation_msg=\"Please select an answer for Q.7.C\" validate_sub_quid=\"true\"
mandatory_msg=\"Please select an answer for Q.7.C\" disabled=\"\"><label
validation_msg=\"Please select an answer for Q.7.C\" checked=\"true\"
class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-align:justify\">COVID19
Vaccination details</div><div class=\"col-sm-3 p-0 col-12\" style=\"display:
none;\"><ul class=\"mb-0 mb-sm-1 text-right\" style=\"padding-left: 0px;\"><li
id=\"88,88,0,mlife,COVIDDetails\" value=\"Yes\" set_checked=\"true\"
pr-sm-3\">A</div><div class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-
align:justify\">Have you been vaccinated for COVID19?</div><div class=\"col-sm-3 p-
0 col-12\"><ul class=\"mb-0 mb-sm-1 text-right\" style=\"padding-left: 0px;\"><li
answer for Q.8.A\" validate_sub_quid=\"true\"
v_sub_quid=\"8813,8814,8812,8811,8808\" v_mandatory_type=\"fill-all\"
mandatory_msg=\"Please select an answer for Q.8.A\" checked=\"true\"
answer for Q.8.A\" disabled=\"\"><label style=\"margin-left: 5px;margin-right:
css-labelq\">No</label></li></ul></div></div><div class=\"row m-0 p-0 mt-2 mt-sm-2
ch_881\" id=\"1,8808\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-3\"
style=\"display:none\">A</div><div class=\"col-sm-12 col-7 pl-0 pr-0 pr-sm-3\"
style=\"text-align:justify;\">Clients to share Copy of vaccination certificate (or
copy of any official documentation confirming complete vaccination & issued by
the relevant health authority).Please note self-declarations are not
acceptable.</div><div class=\"col-sm-3 p-0 col-12 col-sm-offset-7\"
style=\"display:none\"><input validation_msg=\"Please enter details for Q.8.A.M\"
type=\"text\" name=\"8808,8808,mlife,COVIDDetails\"
id=\"8808,8808,mlife,COVIDDetails\" class=\"text-right date form-control pl-0 pr-4
pb-0 \"
onclick=\"fnMsPersonalopenDatePickerDialog('8808,8808,mlife,COVIDDetails')\"
onkeyup=\"fnRmSpecialCharactersQues('8808,8808,mlife,COVIDDetails')\" value=\"\"
disabled=\"\"></div></div><div class=\"row m-0 p-0 mt-2 mt-sm-2 ch_881\"
id=\"1,8811\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-3\">a</div><div
class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-align:justify\">Date of
administration of the first dose</div><div class=\"col-sm-3 p-0 col-12\"><input
validation_msg=\"Please enter details for Q.8.A.a\" type=\"text\"
name=\"8811,8811,mlife,COVIDDetails\" id=\"8811,8811,mlife,COVIDDetails\"
class=\"text-right date form-control pl-0 pr-4 pb-0 \"
onkeyup=\"fnRmSpecialCharactersQues('8811,8811,mlife,COVIDDetails')\"
onchange=\"fnNotAllowFutureDateInQues('8811,8811,mlife,COVIDDetails');\"
value=\"26/08/2021 \" disabled=\"\"></div></div><div class=\"row m-0 p-0 mt-2 mt-
sm-2 ch_881\" id=\"1,8812\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-
3\">b</div><div
class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-align:justify\">Date of
administration of the second dose</div><div class=\"col-sm-3 p-0 col-12\"><input
validation_msg=\"Please enter details for Q.8.A.b\" type=\"text\"
name=\"8812,8812,mlife,COVIDDetails\" id=\"8812,8812,mlife,COVIDDetails\"
class=\"text-right date form-control pl-0 pr-4 pb-0 \"
onkeyup=\"fnRmSpecialCharactersQues('8812,8812,mlife,COVIDDetails')\"
onchange=\"fnNotAllowFutureDateInQues('8812,8812,mlife,COVIDDetails');\"
value=\"05/10/2021 \" disabled=\"\"></div></div><div class=\"row m-0 p-0 mt-2 mt-
sm-2 ch_881\" id=\"1,8814\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-
3\">c</div><div class=\"col-sm-8 col-7 pl-0 pr-0 pr-sm-3\" style=\"text-
align:justify\">Name of vaccine</div><div class=\"col-sm-3 p-0 col-12\"><input
validation_msg=\"Please enter details for Q.8.A.c\" length_validation_msg=\"Maximum
300 characters are allowed for Q.8.A.c\" type=\"text\"
name=\"8814,8814,mlife,COVIDDetails\" onchange=\"uppercaseChar(id);\"
validate_this=\"true\" v_field_length=\"300\" id=\"8814,8814,mlife,COVIDDetails\"
class=\"text-right form-control pl-0 pr-0 pr-sm-2 pb-0\" value=\"SINOPHARM\"
disabled=\"\"></div></div><div class=\"row m-0 p-0 mt-2 mt-sm-2 ch_881\"
id=\"1,8813\"><div class=\"col-sm-1 col-1 pl-0 pr-0 pl-sm-3 pr-sm-3\">d</div><div
experienced any adverse reaction post vaccination?</div><div class=\"col-sm-3 p-0
col-12\"><ul class=\"mb-0 mb-sm-1 text-right\" style=\"padding-left: 0px;\"><li
answer for Q.8.A.d\" validate_sub_quid=\"true\" v_sub_quid=\"88131\"
v_mandatory_type=\"fill-all\" mandatory_msg=\"Please select an answer for Q.8.A.d\"
answer for Q.8.A.d\" checked=\"true\" disabled=\"\"><label style=\"margin-left:
labelq\">No</label></li></ul></div></div>"},[null],{},
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,null,null,null,"",null,null,"26/08/2021 ","05/10/2021 ","No","SINOPHARM"],[]]

PR1411202212269605 Mlife COVIDDetails Reflexive Data

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PR1411202212269605 Mlife COVIDDetails Reflexive Data

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