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corona_form.html
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corona_form.html
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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">
<html lang="en-US" class="supernova"><head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<link rel="alternate" type="application/json+oembed" href="https://www.jotform.com/oembed/?format=json&url=https%3A%2F%2Fform.jotform.com%2F201553327672454" title="oEmbed Form">
<link rel="alternate" type="text/xml+oembed" href="https://www.jotform.com/oembed/?format=xml&url=https%3A%2F%2Fform.jotform.com%2F201553327672454" title="oEmbed Form">
<meta property="og:title" content="Coronavirus Self Declaration Form" >
<meta property="og:url" content="https://form.jotform.com/201553327672454" >
<meta property="og:description" content="Please click the link to complete this form.">
<meta name="slack-app-id" content="AHNMASS8M">
<link rel="shortcut icon" href="https://upload.wikimedia.org/wikipedia/commons/thumb/8/82/SARS-CoV-2_without_background.png/597px-SARS-CoV-2_without_background.png">
<link rel="canonical" href="https://form.jotform.com/201553327672454" />
<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1" />
<meta name="HandheldFriendly" content="true" />
<title>Coronavirus Self Declaration Form</title>
<link href="https://cdn.jotfor.ms/static/formCss.css?3.3.18227" rel="stylesheet" type="text/css" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/nova.css?3.3.18227" />
<link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.18227" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?themeRevisionID=5dca5ac9a5e86d17235d90c1"/>
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/payment/payment_feature.css?3.3.18227" />
<style type="text/css">
.form-label-left{
width:150px;
}
.form-line{
padding-top:12px;
padding-bottom:12px;
}
.form-label-right{
width:150px;
}
body, html{
margin:0;
padding:0;
background:#fff;
}
.form-all{
margin:0px auto;
padding-top:0px;
width:690px;
color:#555 !important;
font-family:'Trebuchet MS';
font-size:14px;
}
</style>
<style type="text/css" id="form-designer-style">
/* Injected CSS Code */
.form-all:after {
content: "";
display: table;
clear: both;
}
.form-all {
font-family: "Trebuchet MS", sans-serif;
}
.form-all {
width: 690px;
}
.form-label-left,
.form-label-right {
width: 150px;
}
.form-label {
white-space: normal;
}
.form-label.form-label-auto {
display: block;
float: none;
word-break: break-word;
text-align: left;
}
.form-label-left {
display: inline-block;
white-space: normal;
float: left;
text-align: left;
}
.form-label-right {
display: inline-block;
white-space: normal;
float: left;
text-align: right;
}
.form-label-top {
white-space: normal;
display: block;
float: none;
text-align: left;
}
.form-radio-item label:before {
top: 0;
}
.form-all {
font-size: 14px;
}
.form-label {
font-weight: bold;
}
.form-checkbox-item label,
.form-radio-item label {
font-weight: normal;
}
.supernova {
background-color: #ffffff;
background-color: #f5f5f5;
}
.supernova body {
background-color: transparent;
}
/*
@width30: (unit(@formWidth, px) + 60px);
@width60: (unit(@formWidth, px)+ 120px);
@width90: (unit(@formWidth, px)+ 180px);
*/
/* | */
@media screen and (min-width: 480px) {
.supernova .form-all {
border: 1px solid #dcdcdc;
-webkit-box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);
-moz-box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);
box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);
}
}
/* | */
/* | */
@media screen and (max-width: 480px) {
.jotform-form .form-all {
margin: 0;
width: 100%;
}
}
/* | */
/* | */
@media screen and (min-width: 480px) and (max-width: 767px) {
.jotform-form .form-all {
margin: 0;
width: 100%;
}
}
/* | */
/* | */
@media screen and (min-width: 480px) and (max-width: 689px) {
.jotform-form .form-all {
margin: 0;
width: 100%;
}
}
/* | */
/* | */
@media screen and (min-width: 768px) {
.jotform-form {
padding: 60px 0;
}
}
/* | */
/* | */
@media screen and (max-width: 689px) {
.jotform-form .form-all {
margin: 0;
width: 100%;
}
}
/* | */
.supernova .form-all,
.form-all {
background-color: #ffffff;
border: 1px solid transparent;
}
.form-header-group {
border-color: #e6e6e6;
}
.form-matrix-table tr {
border-color: #e6e6e6;
}
.form-matrix-table tr:nth-child(2n) {
background-color: #f2f2f2;
}
.form-all {
color: #555555;
}
.form-header-group .form-header {
color: #555555;
}
.form-header-group .form-subHeader {
color: #6f6f6f;
}
.form-sub-label {
color: #6f6f6f;
}
.form-label-top,
.form-label-left,
.form-label-right,
.form-html {
color: #555555;
}
.form-checkbox-item label,
.form-radio-item label {
color: #6f6f6f;
}
.form-line.form-line-active {
-webkit-transition-property: all;
-moz-transition-property: all;
-ms-transition-property: all;
-o-transition-property: all;
transition-property: all;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
background-color: #ffffe0;
}
/* omer */
.form-radio-item,
.form-checkbox-item {
padding-bottom: 0px !important;
}
.form-radio-item:last-child,
.form-checkbox-item:last-child {
padding-bottom: 0;
}
/* omer */
.form-single-column .form-checkbox-item,
.form-single-column .form-radio-item {
width: 100%;
}
.form-checkbox-item .editor-container div,
.form-radio-item .editor-container div {
position: relative;
}
.form-checkbox-item .editor-container div:before,
.form-radio-item .editor-container div:before {
display: inline-block;
vertical-align: middle;
-moz-box-sizing: border-box;
-webkit-box-sizing: border-box;
box-sizing: border-box;
left: 0;
width: 18px;
height: 18px;
}
.supernova {
height: 100%;
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-repeat: repeat;
}
.supernova {
background-image: none;
}
#stage {
background-image: none;
}
/* | */
.form-all {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-repeat: repeat;
}
.form-header-group {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
}
.form-line {
margin-top: 12px;
margin-bottom: 12px;
}
.form-line {
padding: 12px 36px;
}
.form-all .form-textbox,
.form-all .form-radio-other-input,
.form-all .form-checkbox-other-input,
.form-all .form-captcha input,
.form-all .form-spinner input,
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next,
.form-all .qq-upload-button,
.form-all .form-error-message {
-webkit-border-radius: 6px;
-moz-border-radius: 6px;
border-radius: 6px;
}
.form-all .form-sub-label {
margin-left: 3px;
}
.form-all .form-textarea {
-webkit-border-radius: 6px;
-moz-border-radius: 6px;
border-radius: 6px;
}
.form-all .qq-upload-button,
.form-all .form-submit-button,
.form-all .form-submit-reset,
.form-all .form-submit-print {
width: 200px;
font-size: 1em;
padding: 9px 15px;
font-family: "Trebuchet MS", sans-serif;
font-size: 14px;
font-weight: normal;
}
.form-all .qq-upload-button,
.form-all .form-submit-button,
.form-all .form-submit-reset,
.form-all .form-submit-print {
color: #ffffff !important;
background: #bb1f03;
box-shadow: none;
text-shadow: none;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
font-size: 1em;
padding: 9px 15px;
font-family: "Trebuchet MS", sans-serif;
font-size: 14px;
font-weight: normal;
}
/*
& when ( @buttonFontType = google ) {
@import (css) "@{buttonFontLink}";
}
*/
h2.form-header {
line-height: 1.618em;
font-size: 1.714em;
}
h2 ~ .form-subHeader {
line-height: 1.5em;
font-size: 1.071em;
}
.form-header-group {
text-align: left;
}
/*.form-dropdown,
.form-radio-item,
.form-checkbox-item,
.form-radio-other-input,
.form-checkbox-other-input,*/
.form-captcha input,
.form-spinner input,
.form-error-message {
padding: 4px 3px 2px 3px;
}
.form-header-group {
font-family: "Trebuchet MS", sans-serif;
}
.form-section {
padding: 0px 0px 0px 0px;
}
.form-header-group {
margin: 12px 36px 12px 36px;
}
.form-header-group {
padding: 24px 0px 24px 0px;
}
.form-textbox,
.form-textarea {
padding: 4px 3px 2px 3px;
}
.form-textbox,
.form-textarea,
.form-radio-other-input,
.form-checkbox-other-input,
.form-captcha input,
.form-spinner input {
background-color: #ffffff;
}
.form-textbox {
height: 25px;
}
[data-type="control_dropdown"] .form-input,
[data-type="control_dropdown"] .form-input-wide {
width: 150px;
}
.form-buttons-wrapper {
margin-left: 0 !important;
text-align: center;
}
.form-label {
font-family: "Trebuchet MS", sans-serif;
}
li[data-type="control_image"] div {
text-align: left;
}
li[data-type="control_image"] img {
border: none;
border-width: 0px !important;
border-style: solid !important;
border-color: false !important;
}
.form-line-column {
width: auto;
}
.form-line-error {
overflow: hidden;
-webkit-transition-property: none;
-moz-transition-property: none;
-ms-transition-property: none;
-o-transition-property: none;
transition-property: none;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
background-color: #fff4f4;
}
.form-line-error .form-error-message {
background-color: #ff3200;
clear: both;
float: none;
}
.form-line-error .form-error-message .form-error-arrow {
border-bottom-color: #ff3200;
}
.form-line-error input:not(#coupon-input),
.form-line-error textarea,
.form-line-error .form-validation-error {
border: 1px solid #ff3200;
-webkit-box-shadow: 0 0 3px #ff3200;
-moz-box-shadow: 0 0 3px #ff3200;
box-shadow: 0 0 3px #ff3200;
}
.ie-8 .form-all {
margin-top: auto;
margin-top: initial;
}
.ie-8 .form-all:before {
display: none;
}
[data-type="control_clear"] {
display: none;
}
/* | */
@media screen and (max-width: 480px), screen and (max-device-width: 767px) and (orientation: portrait), screen and (max-device-width: 415px) and (orientation: landscape) {
.testOne {
letter-spacing: 0;
}
.form-all {
border: 0;
max-width: initial;
}
.form-sub-label-container {
width: 100%;
margin: 0;
margin-right: 0;
float: left;
-moz-box-sizing: border-box;
-webkit-box-sizing: border-box;
box-sizing: border-box;
}
span.form-sub-label-container + span.form-sub-label-container {
margin-right: 0;
}
.form-sub-label {
white-space: normal;
}
.form-address-table td,
.form-address-table th {
padding: 0 1px 10px;
}
.form-submit-button,
.form-submit-print,
.form-submit-reset {
width: 100%;
margin-left: 0!important;
}
div[id*=at_] {
font-size: 14px;
font-weight: 700;
height: 8px;
margin-top: 6px;
}
.showAutoCalendar {
width: 20px;
}
img.form-image {
max-width: 100%;
height: auto;
}
.form-matrix-row-headers {
width: 100%;
word-break: break-all;
min-width: 80px;
}
.form-collapse-table,
.form-header-group {
margin: 0;
}
.form-collapse-table {
height: 100%;
display: inline-block;
width: 100%;
}
.form-collapse-hidden {
display: none !important;
}
.form-input {
width: 100%;
}
.form-label {
width: 100% !important;
}
.form-label-left,
.form-label-right {
display: block;
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Coronavirus Self Declaration Form
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For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
<br>
Before running our model, take note of the following:
<ul> 1. Use only standard X-ray images. </ul>
<ul> 2. It is an AI-image based COVID-19 detector which works on chest X-Ray images (png, jpg, jpeg). </ul>
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<p>I acknowledge that the information I've given is accurate and complete.</p>
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