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February 2, 2017 16:04
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| { | |
| "name": "GRO_DOH_Citizen_Survey", | |
| "title": "GRO - DOH Citizen Survey", | |
| "sms_keyword": "GRO_DOH_Citizen_Survey", | |
| "default_language": "default", | |
| "version": "1.0", | |
| "id_string": "GRO_DOH_Citizen_Survey", | |
| "type": "survey", | |
| "children": [ | |
| { | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "children": [ | |
| { | |
| "name": "soshanguve", | |
| "label": "Soshanguve \u00e2\u0080\u0093 Block X clinic" | |
| }, | |
| { | |
| "name": "khutsong", | |
| "label": "Khutsong West" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "facility", | |
| "label": "Health Facility Name" | |
| }, | |
| { | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "type": "text", | |
| "name": "surveyor", | |
| "label": "Monitor" | |
| }, | |
| { | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "type": "text", | |
| "name": "capturer", | |
| "label": "Capturer" | |
| }, | |
| { | |
| "name": "visit_reason", | |
| "from_path": "What_was_your_reason_for_visit", | |
| "hint": "Select all that apply to you", | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "label": "What was your reason for visiting the facility?", | |
| "type": "select all that apply", | |
| "children": [ | |
| { | |
| "name": "not_well", | |
| "from_name": "_generally_not_feeling_well", | |
| "label": "Generally not feeling well" | |
| }, | |
| { | |
| "name": "pregnant", | |
| "from_name": "_pregnant_mother_and_children", | |
| "label": "Pregnant mother and children" | |
| }, | |
| { | |
| "name": "emergency", | |
| "from_name": "emergency", | |
| "label": "Emergency" | |
| }, | |
| { | |
| "name": "accompanying", | |
| "from_name": "_accompanying_someone_else", | |
| "label": "Accompanying someone else" | |
| }, | |
| { | |
| "name": "regular_collection", | |
| "from_name": "_i_visit_regularly_to_collect_", | |
| "label": "I visit regularly to collect monthly medication and/or check up" | |
| }, | |
| { | |
| "name": "other", | |
| "from_name": "_other", | |
| "label": "Other (please specify)" | |
| } | |
| ] | |
| }, | |
| { | |
| "bind": { | |
| "relevant": "selected(${What_was_your_reason_for_visit}, '_other')", | |
| "required": "false" | |
| }, | |
| "type": "text", | |
| "name": "Other_reason_for_visiting_the_", | |
| "label": "Other reason for visiting the facility:" | |
| }, | |
| { | |
| "name": "travel_distance", | |
| "from_path": "How_far_did_you_travel_to_get_", | |
| "hint": "Assist the respondent to calculate the distance from their house", | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "label": "How far did you travel to get to the clinic?", | |
| "type": "select one", | |
| "children": [ | |
| { | |
| "name": "under_two", | |
| "from_name": "2km_or_less", | |
| "label": "2km or less" | |
| }, | |
| { | |
| "name": "two_five", | |
| "from_name": "3___5km", | |
| "label": "3 - 5km" | |
| }, | |
| { | |
| "name": "six_eight", | |
| "from_name": "6___8km", | |
| "label": "6 - 8km" | |
| }, | |
| { | |
| "name": "more_eight", | |
| "from_name": "more_than_8km", | |
| "label": "More than 8km" | |
| } | |
| ] | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "nothing", | |
| "label": "Nothing" | |
| }, | |
| { | |
| "name": "less_than_r10", | |
| "label": "Less than R10" | |
| }, | |
| { | |
| "name": "r11___r25", | |
| "label": "R11 - R25" | |
| }, | |
| { | |
| "name": "r26___r50", | |
| "label": "R26 - R50" | |
| }, | |
| { | |
| "name": "r51___r75", | |
| "label": "R51 - R75" | |
| }, | |
| { | |
| "name": "more_than_r75", | |
| "label": "More than R75" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "What_was_the_total_amount_you_", | |
| "label": "What was the total amount you had to pay for transport to the service office?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "from_name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "from_name": "no", | |
| "label": "No" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "distance", | |
| "from_path": "Is_this_clinic_the_nearest_hea", | |
| "label": "Is this clinic the nearest health facility to your home?" | |
| }, | |
| { | |
| "children": [ | |
| { | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "children": [ | |
| { | |
| "name": "more_four", | |
| "from_name": "more_than_4_ho", | |
| "label": "More than 4 hours" | |
| }, | |
| { | |
| "name": "three_four", | |
| "from_name": "3___4_hours", | |
| "label": "3 - 4 hours" | |
| }, | |
| { | |
| "name": "two_three", | |
| "from_name": "2___3_hours", | |
| "label": "2 - 3 hours" | |
| }, | |
| { | |
| "name": "one_two", | |
| "from_name": "1___2_hours", | |
| "label": "1 - 2 hours" | |
| }, | |
| { | |
| "name": "under_one", | |
| "from_name": "less_than_1_ho", | |
| "label": "Less than 1 hour" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "register_time", | |
| "from_path": "Waiting_Times/get_registered_at_reception", | |
| "label": "Get registered at reception" | |
| }, | |
| { | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "children": [ | |
| { | |
| "name": "more_four", | |
| "from_name": "more_than_4_ho", | |
| "label": "More than 4 hours" | |
| }, | |
| { | |
| "name": "three_four", | |
| "from_name": "3___4_hours", | |
| "label": "3 - 4 hours" | |
| }, | |
| { | |
| "name": "two_three", | |
| "from_name": "2___3_hours", | |
| "label": "2 - 3 hours" | |
| }, | |
| { | |
| "name": "one_two", | |
| "from_name": "1___2_hours", | |
| "label": "1 - 2 hours" | |
| }, | |
| { | |
| "name": "under_one", | |
| "from_name": "less_than_1_ho", | |
| "label": "Less than 1 hour" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "professional_time", | |
| "from_path": "Waiting_Times/see_a_professional_nurse_or_doctor_", | |
| "label": "See a professional (nurse or doctor)" | |
| }, | |
| { | |
| "bind": { | |
| "required": "yes" | |
| }, | |
| "children": [ | |
| { | |
| "name": "more_four", | |
| "from_name": "more_than_4_ho", | |
| "label": "More than 4 hours" | |
| }, | |
| { | |
| "name": "three_four", | |
| "from_name": "3___4_hours", | |
| "label": "3 - 4 hours" | |
| }, | |
| { | |
| "name": "two_three", | |
| "from_name": "2___3_hours", | |
| "label": "2 - 3 hours" | |
| }, | |
| { | |
| "name": "one_two", | |
| "from_name": "1___2_hours", | |
| "label": "1 - 2 hours" | |
| }, | |
| { | |
| "name": "under_one", | |
| "from_name": "less_than_1_ho", | |
| "label": "Less than 1 hour" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "medicine_time", | |
| "from_path": "Waiting_Times/collect_your_medication", | |
| "label": "Collect your medication" | |
| } | |
| ], | |
| "type": "group", | |
| "name": "waiting_group", | |
| "label": "Please tell us how long you waited to:" | |
| }, | |
| { | |
| "children": [ | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "not_applicable", | |
| "label": "Not Applicable" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Did_you_feel_safe_in_and_aroun", | |
| "name": "safety", | |
| "label": "Did you feel safe in and around the clinic?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "not_applicable", | |
| "label": "Not Applicable" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Did_the_staff_respect_your_rig", | |
| "name": "examined_private", | |
| "label": "Did the staff respect your right to be examined in private?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "not_applicable", | |
| "label": "Not Applicable" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Did_the_nurse_or_doctor_explai", | |
| "name": "consent", | |
| "label": "Did the nurse or doctor explain your rights and ask for your consent before treating you?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "not_applicable", | |
| "label": "Not Applicable" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Did_you_get_all_the_medication", | |
| "name": "all_medication", | |
| "label": "Did you get all the medication that you needed?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "not_applicable", | |
| "label": "Not Applicable" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Do_you_know_how_to_make_a_comp", | |
| "name": "complaint", | |
| "label": "Do you know how to make a complaint at this clinic if you wanted to?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "not_applicable", | |
| "label": "Not Applicable" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "complaint_response", | |
| "from_path": "Do_you_think_that_the_clinic_w", | |
| "label": "Do you think that the clinic will respond to a complaint if you make one? *" | |
| } | |
| ], | |
| "type": "group", | |
| "name": "yes_no_group", | |
| "label": "Please answer yes or no to the following questions" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "type": "text", | |
| "name": "Would_you_like_to_mention_any_", | |
| "label": "Would you like to mention any personal experience related to any of these questions?" | |
| }, | |
| { | |
| "control": { | |
| "appearance": "field-list" | |
| }, | |
| "type": "group", | |
| "name": "performance_group", | |
| "children": [ | |
| { | |
| "control": { | |
| "appearance": "label" | |
| }, | |
| "children": [ | |
| { | |
| "name": "very_poor", | |
| "label": "Very poor" | |
| }, | |
| { | |
| "name": "poor", | |
| "label": "Poor" | |
| }, | |
| { | |
| "name": "not_good__not_", | |
| "label": "Not good, not bad" | |
| }, | |
| { | |
| "name": "good", | |
| "label": "Good" | |
| }, | |
| { | |
| "name": "excellent", | |
| "label": "Excellent" | |
| } | |
| ], | |
| "type": "select one", | |
| "name": "How_would_you_rate_the_perform_header", | |
| "label": "How would you rate the performance of the clinic staff in the following areas?" | |
| }, | |
| { | |
| "control": { | |
| "appearance": "list-nolabel" | |
| }, | |
| "from_path": "How_would_you_rate_the_perform/was_the_clinic_clean_", | |
| "name": "clean", | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "label": "Was the clinic clean?", | |
| "type": "select one", | |
| "children": [ | |
| { | |
| "from_name": "very_poor", | |
| "name": "1", | |
| "label": "Very poor" | |
| }, | |
| { | |
| "from_name": "poor", | |
| "name": "2", | |
| "label": "Poor" | |
| }, | |
| { | |
| "from_name": "not_good__not_", | |
| "name": "3", | |
| "label": "Not good, not bad" | |
| }, | |
| { | |
| "from_name": "good", | |
| "name": "4", | |
| "label": "Good" | |
| }, | |
| { | |
| "from_name": "excellent", | |
| "name": "5", | |
| "label": "Excellent" | |
| } | |
| ] | |
| }, | |
| { | |
| "control": { | |
| "appearance": "list-nolabel" | |
| }, | |
| "from_path": "How_would_you_rate_the_perform/did_the_clinic_manage_queues_well_", | |
| "name": "queues", | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "label": "Did the clinic manage queues well?", | |
| "type": "select one", | |
| "children": [ | |
| { | |
| "from_name": "very_poor", | |
| "name": "1", | |
| "label": "Very poor" | |
| }, | |
| { | |
| "from_name": "poor", | |
| "name": "2", | |
| "label": "Poor" | |
| }, | |
| { | |
| "from_name": "not_good__not_", | |
| "name": "3", | |
| "label": "Not good, not bad" | |
| }, | |
| { | |
| "from_name": "good", | |
| "name": "4", | |
| "label": "Good" | |
| }, | |
| { | |
| "from_name": "excellent", | |
| "name": "5", | |
| "label": "Excellent" | |
| } | |
| ] | |
| }, | |
| { | |
| "control": { | |
| "appearance": "list-nolabel" | |
| }, | |
| "from_path": "How_would_you_rate_the_perform/did_the_administrative_staff_treat_you_respectfully_", | |
| "name": "respect_admin", | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "label": "Did the administrative staff treat you respectfully?", | |
| "type": "select one", | |
| "children": [ | |
| { | |
| "from_name": "very_poor", | |
| "name": "1", | |
| "label": "Very poor" | |
| }, | |
| { | |
| "from_name": "poor", | |
| "name": "2", | |
| "label": "Poor" | |
| }, | |
| { | |
| "from_name": "not_good__not_", | |
| "name": "3", | |
| "label": "Not good, not bad" | |
| }, | |
| { | |
| "from_name": "good", | |
| "name": "4", | |
| "label": "Good" | |
| }, | |
| { | |
| "from_name": "excellent", | |
| "name": "5", | |
| "label": "Excellent" | |
| } | |
| ] | |
| }, | |
| { | |
| "control": { | |
| "appearance": "list-nolabel" | |
| }, | |
| "from_path": "How_would_you_rate_the_perform/did_the_health_professionals_doctors_and_nurses_treat_you_respectfully_", | |
| "name": "respect_professionals", | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "label": "Did the health professionals (doctors and nurses) treat you respectfully?", | |
| "type": "select one", | |
| "children": [ | |
| { | |
| "from_name": "very_poor", | |
| "name": "1", | |
| "label": "Very poor" | |
| }, | |
| { | |
| "from_name": "poor", | |
| "name": "2", | |
| "label": "Poor" | |
| }, | |
| { | |
| "from_name": "not_good__not_", | |
| "name": "3", | |
| "label": "Not good, not bad" | |
| }, | |
| { | |
| "from_name": "good", | |
| "name": "4", | |
| "label": "Good" | |
| }, | |
| { | |
| "from_name": "excellent", | |
| "name": "5", | |
| "label": "Excellent" | |
| } | |
| ] | |
| }, | |
| { | |
| "control": { | |
| "appearance": "list-nolabel" | |
| }, | |
| "from_path": "How_would_you_rate_the_perform/how_good_are_the_ambulance_services_", | |
| "name": "ambulance", | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "label": "How good are the ambulance services?", | |
| "type": "select one", | |
| "children": [ | |
| { | |
| "from_name": "very_poor", | |
| "name": "1", | |
| "label": "Very poor" | |
| }, | |
| { | |
| "from_name": "poor", | |
| "name": "2", | |
| "label": "Poor" | |
| }, | |
| { | |
| "from_name": "not_good__not_", | |
| "name": "3", | |
| "label": "Not good, not bad" | |
| }, | |
| { | |
| "from_name": "good", | |
| "name": "4", | |
| "label": "Good" | |
| }, | |
| { | |
| "from_name": "excellent", | |
| "name": "5", | |
| "label": "Excellent" | |
| } | |
| ] | |
| }, | |
| { | |
| "control": { | |
| "appearance": "list-nolabel" | |
| }, | |
| "from_path": "How_would_you_rate_the_perform/does_the_clinic_have_the_necessary_equipment_in_good_working_condition_to_provide_the_services_you_need_", | |
| "name": "equipment", | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "label": "Does the clinic have the necessary equipment in good working condition to provide the services you need?", | |
| "type": "select one", | |
| "children": [ | |
| { | |
| "from_name": "very_poor", | |
| "name": "1", | |
| "label": "Very poor" | |
| }, | |
| { | |
| "from_name": "poor", | |
| "name": "2", | |
| "label": "Poor" | |
| }, | |
| { | |
| "from_name": "not_good__not_", | |
| "name": "3", | |
| "label": "Not good, not bad" | |
| }, | |
| { | |
| "from_name": "good", | |
| "name": "4", | |
| "label": "Good" | |
| }, | |
| { | |
| "from_name": "excellent", | |
| "name": "5", | |
| "label": "Excellent" | |
| } | |
| ] | |
| } | |
| ] | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "type": "text", | |
| "name": "Would_you_like_to_say_more_abo", | |
| "label": "Would you like to say more about your personal experience at this clinic?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "unsure", | |
| "label": "Unsure" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Does_this_clinic_have_a_Clinic", | |
| "name": "clinic_committee", | |
| "label": "Does this clinic have a Clinic Committee?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Do_you_know_what_the_Clinic_Co", | |
| "name": "clinic_committee_function", | |
| "label": "Do you know what the Clinic Committee should do?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| }, | |
| { | |
| "name": "maybe", | |
| "label": "Maybe" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Do_you_think_that_this_clinic_", | |
| "name": "clinic_feedback", | |
| "label": "Do you think that this clinic will learn from this survey and improve their services?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "type": "text", | |
| "name": "What_improvements_would_you_mo", | |
| "label": "What improvements would you most like to see at this clinic?" | |
| }, | |
| { | |
| "children": [ | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "male", | |
| "label": "Male" | |
| }, | |
| { | |
| "name": "female", | |
| "label": "Female" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Select_your_gender", | |
| "name": "gender", | |
| "label": "Select your gender" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "from_name": "under_25_years", | |
| "name": "under_25", | |
| "label": "Under 25 years old" | |
| }, | |
| { | |
| "from_name": "26___40_years_", | |
| "name": "26_40", | |
| "label": "26 - 40 years old" | |
| }, | |
| { | |
| "name": "41_60", | |
| "from_name": "41___60_years_", | |
| "label": "41 - 60 years old" | |
| }, | |
| { | |
| "name": "older_60", | |
| "from_name": "older_than_60_", | |
| "label": "Older than 60 years" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "How_old_are_you", | |
| "name": "age", | |
| "label": "How old are you?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "name": "yes", | |
| "label": "Yes" | |
| }, | |
| { | |
| "name": "no", | |
| "label": "No" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Do_you_have_any_disabilities", | |
| "name": "disability", | |
| "label": "Do you have any disabilities?" | |
| }, | |
| { | |
| "bind": { | |
| "required": "true" | |
| }, | |
| "children": [ | |
| { | |
| "from_name": "i_do_not_earn_", | |
| "name": "none", | |
| "label": "I do not earn an income" | |
| }, | |
| { | |
| "from_name": "government_gra", | |
| "name": "gov_grant", | |
| "label": "Government grant" | |
| }, | |
| { | |
| "name": "temp_employ", | |
| "from_name": "temporary_empl", | |
| "label": "Temporary employment" | |
| }, | |
| { | |
| "name": "perm_employ", | |
| "from_name": "permanent_empl", | |
| "label": "Permanent employment" | |
| }, | |
| { | |
| "name": "small_vendor", | |
| "from_name": "small_scale_ve", | |
| "label": "Small scale vendor (no employees)" | |
| }, | |
| { | |
| "name": "own_business", | |
| "from_name": "own_business__", | |
| "label": "Own business (with employees)" | |
| } | |
| ], | |
| "type": "select one", | |
| "from_path": "Where_do_you_earn_most_of_your", | |
| "name": "income", | |
| "label": "Where do you earn most of your income from?" | |
| } | |
| ], | |
| "type": "group", | |
| "name": "demographics_group", | |
| "label": "Some questions about you" | |
| }, | |
| { | |
| "type": "start", | |
| "name": "start" | |
| }, | |
| { | |
| "type": "end", | |
| "name": "end" | |
| }, | |
| { | |
| "type": "today", | |
| "name": "today" | |
| }, | |
| { | |
| "control": { | |
| "bodyless": true | |
| }, | |
| "type": "group", | |
| "name": "meta", | |
| "children": [ | |
| { | |
| "bind": { | |
| "readonly": "true()", | |
| "calculate": "concat('uuid:', uuid())" | |
| }, | |
| "type": "calculate", | |
| "name": "instanceID" | |
| } | |
| ] | |
| } | |
| ] | |
| } |
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