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Created October 17, 2024 19:41
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{
"title": "Annual Monitoring Form",
"name": "annualMonitoringForm",
"type": "form",
"components": [
{
"tableView": true,
"input": true,
"collapsible": false,
"type": "panel",
"title": "Page 1",
"components": [
null,
{
"tableView": true,
"input": true,
"key": "wx6b3d42",
"size": "medium",
"type": "textfield",
"label": "Agency or Company",
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"key": "2z0j5s9h",
"size": "medium",
"type": "textfield",
"label": "Role ",
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"inputMask": "999-999-9999",
"validateOn": "blur",
"key": "y7fn4368",
"type": "phoneNumber",
"label": "Contact Phone Number",
"validate": {
"required": true
}
},
null,
{
"tableView": true,
"input": true,
"key": "5pfxmg0u",
"size": "medium",
"type": "textfield",
"label": "Name of Sponsor/Agency",
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"key": "1e1c2m1t",
"size": "medium",
"type": "textfield",
"label": "Name of Property Management Company",
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"key": "x22czo68",
"size": "medium",
"type": "textfield",
"label": "Name of Service Provider (if applicable)",
"validate": {
"required": true
}
}
],
"key": "page1"
},
null,
{
"tableView": true,
"input": true,
"collapsible": false,
"type": "panel",
"title": "Page 2",
"components": [
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "5sabxj45",
"label": "Services in senior-restricted buildings<br><br>Please report on (7) service areas provided at the senior-restricted Buildings. The areas are as follows: 1) Annual resident assessments; 2) Non-housing basic needs; 3) Community-building activities; 4) Training and skill development; 5) Service coordination and linkages; 6) Other services; and 7) Program learnings.\n\nEligible supportive services, categories and examples are provided. \n\nThe reporting period covers January 1 - December 31, 2023.",
"components": [
null
]
},
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "vl9say8m",
"label": "Annual Resident Assessments<br><br>Annual assessments include need assessments and resident satisfaction survey.",
"components": [
{
"tableView": true,
"input": true,
"key": "baiq5h4q",
"type": "radio",
"label": "Needs assessments are distributed at this site.",
"conditions": [],
"description": "",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
null,
null,
{
"tableView": true,
"input": true,
"delimiter": false,
"requireDecimal": false,
"inputFormat": "plain",
"truncateMultipleSpaces": false,
"validateOn": "blur",
"key": "qrtrzi7t",
"type": "number",
"label": "# of resident surveys collected",
"conditions": [
{
"value": "Yes",
"action": "show",
"method": "eq",
"response_field_id": "baiq5h4q"
}
],
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"key": "qw5kioxh",
"type": "radio",
"label": "Residents satisfaction surveys are distributed at this site. ",
"conditions": [],
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
null,
null,
{
"tableView": true,
"input": true,
"delimiter": false,
"requireDecimal": false,
"inputFormat": "plain",
"truncateMultipleSpaces": false,
"validateOn": "blur",
"key": "r159fyke",
"type": "number",
"label": "# of resident surveys collected ",
"conditions": [
{
"value": "Yes",
"action": "show",
"method": "eq",
"response_field_id": "qw5kioxh"
}
],
"validate": {
"required": true
}
}
]
}
],
"key": "page2"
},
null,
{
"tableView": true,
"input": true,
"collapsible": false,
"type": "panel",
"title": "Page 3",
"components": [
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "87l41md1",
"label": "Non-Housing Basic Needs<br><br>Non-housing basic needs includes but not limited to food pantry, transportation support, utility financial assistance.",
"components": [
{
"tableView": true,
"input": true,
"key": "k636k9a7",
"type": "radio",
"label": "Access to food, such as food pantry or meal deliveries are offered on-site.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "lfsxlh2a",
"label": "Food access service provided.",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. food pantry, world kitchen delivery)",
"type": "textfield",
"key": "enterServiceNameEGFoodPantry"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (E.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity ",
"type": "textfield",
"key": "OfHoursPerActivity"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting"
}
],
"conditional": {
"show": true,
"when": "k636k9a7",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "d6ftyp3t",
"type": "radio",
"label": "Utility financial assistance is offered on-site.",
"description": "E.g. Utility deposit",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "xspgiw1f",
"label": "Utility financial assistance service provided.",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. Utility deposit, on-going assistance)",
"type": "textfield",
"key": "enterServiceNameEGUtilityDeposit"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (E.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly1"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity1"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting1"
},
{
"tableView": true,
"input": true,
"label": "Enter utility provider",
"type": "textfield",
"key": "enterUtilityProvider"
}
],
"conditional": {
"show": true,
"when": "d6ftyp3t",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "ozj2r1oj",
"type": "radio",
"label": "Transportation support services are offered on-site.",
"description": "E.g. Transportation, discounted tokens ",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "5s84f1qj",
"label": "Transportation support services provided.",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. GoGoGranparent, Lyft coordination) ",
"type": "textfield",
"key": "enterServiceNameEGGoGoGranparent"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (E.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly2"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity2"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting2"
}
],
"conditional": {
"show": true,
"when": "ozj2r1oj",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "4a5hlsko",
"type": "radio",
"label": "Other services offered to meet Non-housing basic needs.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "6hkq25wq",
"label": "Service provided",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter Other Service(s)",
"type": "textfield",
"key": "enterOtherServiceS"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly3"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity3"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting3"
}
],
"conditional": {
"show": true,
"when": "4a5hlsko",
"eq": true
}
}
]
},
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "u9n4x53v",
"label": "Community Building",
"components": [
{
"tableView": true,
"input": true,
"key": "vnlgjp7y",
"type": "radio",
"label": "Social events and gatherings are offered on-site.",
"description": "E.g. Movie night, outings, seasonal or cultural gatherings",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "uzhrmp09",
"label": "Social Events",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (E.g. Coffee Korner, Spring Gathering)",
"type": "textfield",
"key": "enterServiceNameEGCoffeeKorner"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (E.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly4"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity4"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting4"
}
],
"conditional": {
"show": true,
"when": "vnlgjp7y",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "ophd43zb",
"type": "radio",
"label": "Group excercise classes are offered on-site.",
"description": "E.g. Chair yoga, Zumba",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "alfeodkh",
"label": "Group Class Excercises (CD2)",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. Zumba, Chair yoga)",
"type": "textfield",
"key": "enterServiceNameEGZumbaChairYoga"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly5"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity5"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting5"
}
],
"conditional": {
"show": true,
"when": "ophd43zb",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "xumq00yk",
"type": "radio",
"label": "Enrichment classes are offered on-site.",
"description": "E.g. Art and crafting classes",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "1dgb0ffv",
"label": "Enrichment Classes ",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. Knitting Korner, Paint and Tea)",
"type": "textfield",
"key": "enterServiceNameEGKnittingKorner"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly6"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity6"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting6"
}
],
"conditional": {
"show": true,
"when": "xumq00yk",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "o9lhtp1i",
"type": "radio",
"label": "Other community building services are offered.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "gebe1esl",
"label": "Community building, Other services provided.",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter Other Service(s)",
"type": "textfield",
"key": "enterOtherServiceS1"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly7"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity7"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting7"
}
],
"conditional": {
"show": true,
"when": "o9lhtp1i",
"eq": true
}
}
]
},
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "cdms0of7",
"label": "Training and Skill Development",
"components": [
{
"tableView": true,
"input": true,
"key": "hnjr29mt",
"type": "radio",
"label": "Educational services are offered on-site.",
"description": "E.g. GED, ESL classes",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "pghbair6",
"label": "Education Services",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. GED classes, ESL classes)",
"type": "textfield",
"key": "enterServiceNameEGGEDClasses"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly8"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity8"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting8"
}
],
"conditional": {
"show": true,
"when": "hnjr29mt",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "agitpqtd",
"type": "radio",
"label": "Life skills trainings are offered on-site.",
"description": "E.g. Computer and/or Internet classes ",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "81muljde",
"label": "Life skills trainings",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. Internet classes)",
"type": "textfield",
"key": "enterServiceNameEGInternet"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly9"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity9"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting9"
}
],
"conditional": {
"show": true,
"when": "agitpqtd",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "3d1008yi",
"type": "radio",
"label": "Employment assistance and job trainings are offered on-site.",
"description": "E.g. Resume writing, Jobs search",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "z92ksnsm",
"label": "Employment assistance and job trainings. ",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. Resume writing, Jobs for Retirees)",
"type": "textfield",
"key": "enterServiceNameEGResumeWriting"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly10"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity10"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting10"
}
],
"conditional": {
"show": true,
"when": "3d1008yi",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "lu9ttmpi",
"type": "radio",
"label": "Other training and skill development classes are offered on-site.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "dsz3nhxh",
"label": "Other training and skill development service provided",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter Other Service(s)",
"type": "textfield",
"key": "enterOtherServiceS2"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly11"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity11"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting11"
}
],
"conditional": {
"show": true,
"when": "lu9ttmpi",
"eq": true
}
}
]
},
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "129v88f8",
"label": "Service Coordination and Linkages",
"components": [
{
"tableView": true,
"input": true,
"key": "5ewk0dvj",
"type": "radio",
"label": "Individual case management is offered on-site.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "f1f3p31s",
"label": "Individual case management services",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter frequency (E.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly12"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity12"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting12"
}
],
"conditional": {
"show": true,
"when": "5ewk0dvj",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "yx4i6o0h",
"type": "radio",
"label": "Mental health services are offered on-site.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "xvodfbth",
"label": "Mental health services",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. Elder group, Individual Counseling)",
"type": "textfield",
"key": "enterServiceNameEGElderGroup"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly13"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity13"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting13"
}
],
"conditional": {
"show": true,
"when": "yx4i6o0h",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "g6h9h4ou",
"type": "radio",
"label": "Outpatient services are offered on-site.",
"description": "e.g Prevention and Screening",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "t0fahetw",
"label": "Outpatient services",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter service name (e.g. Prevention and Screening)",
"type": "textfield",
"key": "enterServiceNameEGPreventionAnd"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (e.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly14"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity14"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting14"
}
],
"conditional": {
"show": true,
"when": "g6h9h4ou",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "4lp5y3qj",
"type": "radio",
"label": "Substance abuse treatment services are offered on-site.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "ggyqt2i4",
"label": "Substance abuse treatment services.",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter frequency (E.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly15"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity15"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting15"
}
],
"conditional": {
"show": true,
"when": "4lp5y3qj",
"eq": true
}
},
{
"tableView": true,
"input": true,
"key": "dcmsjcp7",
"type": "radio",
"label": "Other coordination or linkage services are offered",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "vxkasjy5",
"label": "Other service coordination and linkages provided ",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter Other Service(s)",
"type": "textfield",
"key": "enterOtherServiceS3"
},
{
"tableView": true,
"input": true,
"label": "Frequency (Enter: Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "frequencyEnterDailyWeeklyMonthly"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity16"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting16"
}
],
"conditional": {
"show": true,
"when": "dcmsjcp7",
"eq": true
}
},
{
"tableView": true,
"input": true,
"autoExpand": true,
"key": "d53fx5r6",
"size": "medium",
"type": "textarea",
"label": "List top 3 internal referrals: ",
"description": "Internal service coordination referrals include services hosted by either sponsor or building service provider. Services can be on-site or at another location (e.g. food bank, seasonal gatherings). ",
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"autoExpand": true,
"key": "mmxx8pgx",
"size": "medium",
"type": "textarea",
"label": "List top 3 external referrals: ",
"description": "External service coordination referrals include services that are through another organization. Services can be on-site or at another location (e.g. medical care, flu shots, psycho-educational groups).",
"validate": {
"required": true
}
}
]
},
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "rywn0mtg",
"label": "Other services",
"components": [
{
"tableView": true,
"input": true,
"key": "pbkv04ja",
"type": "radio",
"label": "Other services, not mentioned above, are offered on-site.",
"values": [
{
"label": "Yes",
"value": true
},
{
"label": "No",
"value": false
}
],
"validate": {
"required": true
}
},
{
"type": "datagrid",
"reorder": false,
"addAnotherPosition": "bottom",
"layoutFixed": true,
"enableRowGroups": false,
"initEmpty": false,
"tableView": false,
"input": true,
"defaultValue": [
{}
],
"key": "oom06gia",
"label": "Other senior-restricted building services provided.",
"required": true,
"components": [
{
"tableView": true,
"input": true,
"label": "Enter Other Service(s)",
"type": "textfield",
"key": "enterOtherServiceS4"
},
{
"tableView": true,
"input": true,
"label": "Enter frequency (E.g. Daily, Weekly, Monthly, Annually, As Needed)",
"type": "textfield",
"key": "enterFrequencyEGDailyWeekly16"
},
{
"tableView": true,
"input": true,
"label": "# of hours per activity",
"type": "textfield",
"key": "OfHoursPerActivity17"
},
{
"tableView": true,
"input": true,
"label": "# of total served during reporting period",
"type": "textfield",
"key": "OfTotalServedDuringReporting17"
}
],
"conditional": {
"show": true,
"when": "pbkv04ja",
"eq": true
}
}
]
}
],
"key": "page3"
},
{
"tableView": true,
"input": true,
"collapsible": false,
"type": "panel",
"title": "Page 4",
"components": [
{
"tableView": false,
"input": false,
"type": "fieldSet",
"key": "4a5c30tl",
"label": "Program Learnings",
"components": [
{
"tableView": true,
"input": true,
"autoExpand": true,
"key": "kblop742",
"size": "medium",
"type": "textarea",
"label": "What are the program’s top three (3) strengths?",
"description": "",
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"autoExpand": true,
"key": "ppb5enrw",
"size": "medium",
"type": "textarea",
"label": "What are the program’s top three (3) challenges or areas for improvement?",
"description": "",
"validate": {
"required": true
}
},
{
"tableView": true,
"input": true,
"autoExpand": true,
"key": "mgg0ezzs",
"size": "medium",
"type": "textarea",
"label": "What are the opportunities for the program?",
"description": "",
"validate": {
"required": true
}
}
]
}
],
"key": "page4"
},
null
],
"metadata": {}
}
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