{"id":224,"date":"2020-06-30T13:26:01","date_gmt":"2020-06-30T13:26:01","guid":{"rendered":"https:\/\/apc.edu.za\/?page_id=224"},"modified":"2020-06-30T13:26:01","modified_gmt":"2020-06-30T13:26:01","slug":"covid19-check","status":"publish","type":"page","link":"https:\/\/apc.edu.za\/index.php\/advisor-progressive-college\/covid19-check\/","title":{"rendered":"COVID19 Check"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework gpoll_enabled_wrapper gpoll_block_repeat_voters_wrapper gpoll_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_9' ><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9' class='gpoll_enabled gpoll_block_repeat_voters gpoll' action='\/index.php\/wp-json\/wp\/v2\/pages\/224#gf_9' data-formid='9' novalidate>\n        <div id='gf_progressbar_wrapper_9' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span> - Registration\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_orange' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_orange percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_9_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_9' class='gform_fields top_label form_sublabel_above description_above validation_below'><li id=\"field_9_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_3\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Welcome to the COVID19 risk assessment tool.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_3'>Please help us by answering a few questions about you and your health.\n\nYou will receive advice on what actions to take based on national guidelines, and the data you enter will help us in predictive modelling and planning our national response to COVID-19. \n\nThank you for coming forward and for contributing to the health of all citizens AND stopping the spread of the virus.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_3'><li class='gchoice gchoice_9_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='I accept the terms (Read Terms and Policy)'  id='choice_9_3_1'   aria-describedby=\"gfield_description_9_3\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_3_1' id='label_9_3_1' class='gform-field-label gform-field-label--type-inline'>I accept the terms (Read Terms and Policy)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_9_1' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_2' class='gform_page' data-js='page-field-id-1' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_9_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><li id=\"field_9_4\" class=\"gfield gfield--type-name field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_4\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_4'>\n                            \n                            <span id='input_9_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_9_4_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_4.3' id='input_9_4_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_9_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_9_4_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_4.6' id='input_9_4_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_6\" class=\"gfield gfield--type-select field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_6\" ><label class='gfield_label gform-field-label' for='input_9_6'>How old are you?<\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_9_6' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Under 18' >Under 18<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65 or Above' >65 or Above<\/option><\/select><\/div><\/li><li id=\"field_9_7\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_7\" ><label class='gfield_label gform-field-label' for='input_9_7'>Please provide us with the gender you identify as<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_9_7' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/li><li id=\"field_9_8\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_8\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Sharing your location data will help us to further accurately map cases of COVID-19<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_8_1_container' >\n                                        <label for='input_9_8_1' id='input_9_8_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_8.1' id='input_9_8_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_8_2_container' >\n                                        <label for='input_9_8_2' id='input_9_8_2_label' class='gform-field-label gform-field-label--type-sub '>Township\/Area\/Complex<\/label>\n                                        <input type='text' name='input_8.2' id='input_9_8_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_8_3_container' >\n                                    <label for='input_9_8_3' id='input_9_8_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_8.3' id='input_9_8_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_8_4_container' >\n                                        <label for='input_9_8_4' id='input_9_8_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                        <input type='text' name='input_8.4' id='input_9_8_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_8_5_container' >\n                                    <label for='input_9_8_5' id='input_9_8_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                    <input type='text' name='input_8.5' id='input_9_8_5' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_8_6_container' >\n                                        <label for='input_9_8_6' id='input_9_8_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_8.6' id='input_9_8_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' selected='selected'>South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"1\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"1\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_9' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_3' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_9_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><li id=\"field_9_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_10\" ><label class='gfield_label gform-field-label' >Where are you going today?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_10'>\n\t\t\t<li class='gchoice gchoice_9_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Campus (Student\/Staff)'  id='choice_9_10_0'    \/>\n\t\t\t\t<label for='choice_9_10_0' id='label_9_10_0' class='gform-field-label gform-field-label--type-inline'>Campus (Student\/Staff)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Office'  id='choice_9_10_1'    \/>\n\t\t\t\t<label for='choice_9_10_1' id='label_9_10_1' class='gform-field-label gform-field-label--type-inline'>Office<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_11\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_11\" ><label class='gfield_label gform-field-label' for='input_9_11'>Please select a campus<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_9_11' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='eMalahleni' >eMalahleni<\/option><\/select><\/div><\/li><li id=\"field_9_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_12\" ><label class='gfield_label gform-field-label' >Are you a:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_12'>\n\t\t\t<li class='gchoice gchoice_9_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Student'  id='choice_9_12_0'    \/>\n\t\t\t\t<label for='choice_9_12_0' id='label_9_12_0' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Staff'  id='choice_9_12_1'    \/>\n\t\t\t\t<label for='choice_9_12_1' id='label_9_12_1' class='gform-field-label gform-field-label--type-inline'>Staff<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Visitor'  id='choice_9_12_2'    \/>\n\t\t\t\t<label for='choice_9_12_2' id='label_9_12_2' class='gform-field-label gform-field-label--type-inline'>Visitor<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_13' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_13' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"4\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"4\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_4' class='gform_page' data-js='page-field-id-13' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_9_4' class='gform_fields top_label form_sublabel_above description_above validation_below'><li id=\"field_9_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_14\" ><label class='gfield_label gform-field-label' >Medical History<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_14'>Do you have any other pre-existing medical conditions that we should be aware of?<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_14'>\n\t\t\t<li class='gchoice gchoice_9_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes'  id='choice_9_14_0'    \/>\n\t\t\t\t<label for='choice_9_14_0' id='label_9_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_9_14_1'    \/>\n\t\t\t\t<label for='choice_9_14_1' id='label_9_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='Not sure'  id='choice_9_14_2'    \/>\n\t\t\t\t<label for='choice_9_14_2' id='label_9_14_2' class='gform-field-label gform-field-label--type-inline'>Not sure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_18' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"5\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"5\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_5' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_9_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><li id=\"field_9_15\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_9_15\" ><label class='gfield_label gform-field-label' >Do you feel very hot or cold? Are you sweating or shivering? When you touch your forehead, does it feel hot?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_15'>\n\t\t\t<li class='gchoice gchoice_9_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='gsurvey15395fc73f'  id='choice_9_15_0'    \/>\n\t\t\t\t<label for='choice_9_15_0' id='label_9_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='gsurvey15bbe13344'  id='choice_9_15_1'    \/>\n\t\t\t\t<label for='choice_9_15_1' id='label_9_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_19\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_9_19\" ><label class='gfield_label gform-field-label' >Do you have a cough that recently started?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_19'>\n\t\t\t<li class='gchoice gchoice_9_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='gsurvey15395fc73f'  id='choice_9_19_0'    \/>\n\t\t\t\t<label for='choice_9_19_0' id='label_9_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='gsurvey15bbe13344'  id='choice_9_19_1'    \/>\n\t\t\t\t<label for='choice_9_19_1' id='label_9_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_20\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_9_20\" ><label class='gfield_label gform-field-label' >Do you have a sore throat or pain when swallowing that recently started?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_20'>\n\t\t\t<li class='gchoice gchoice_9_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='gsurvey15395fc73f'  id='choice_9_20_0'    \/>\n\t\t\t\t<label for='choice_9_20_0' id='label_9_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='gsurvey15bbe13344'  id='choice_9_20_1'    \/>\n\t\t\t\t<label for='choice_9_20_1' id='label_9_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_21\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_9_21\" ><label class='gfield_label gform-field-label' >Do you have breathlessness or difficulty in breathing, that you\u2019ve noticed recently?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_21'>\n\t\t\t<li class='gchoice gchoice_9_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='gsurvey15395fc73f'  id='choice_9_21_0'    \/>\n\t\t\t\t<label for='choice_9_21_0' id='label_9_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='gsurvey15bbe13344'  id='choice_9_21_1'    \/>\n\t\t\t\t<label for='choice_9_21_1' id='label_9_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_22\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_9_22\" ><label class='gfield_label gform-field-label' >Have you noticed any recent changes in your ability to taste or smell things?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_22'>\n\t\t\t<li class='gchoice gchoice_9_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='gsurvey15395fc73f'  id='choice_9_22_0'    \/>\n\t\t\t\t<label for='choice_9_22_0' id='label_9_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='gsurvey15bbe13344'  id='choice_9_22_1'    \/>\n\t\t\t\t<label for='choice_9_22_1' id='label_9_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_23\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_9_23\" ><label class='gfield_label gform-field-label' >Have you recently been in close contact to someone confirmed to be infected with COVID-19?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_23'>\n\t\t\t<li class='gchoice gchoice_9_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='gsurvey15395fc73f'  id='choice_9_23_0'    \/>\n\t\t\t\t<label for='choice_9_23_0' id='label_9_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='gsurvey15bbe13344'  id='choice_9_23_1'    \/>\n\t\t\t\t<label for='choice_9_23_1' id='label_9_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_16\" class=\"gfield gfield--type-poll gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible gpoll_field\"  data-field-class=\"gpoll_field\" data-js-reload=\"field_9_16\" ><label class='gfield_label gform-field-label' >Confirmation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_16'>Please confirm that the information you shared is accurate to the best of your knowledge. Once you click the SUBMIT button, you will be unable to complete another HealthCheck for the next 24hours. Please note that the National Department of Health may contact you if necessary based on your responses.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_9_16'>\n\t\t\t<li class='gchoice gchoice_9_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='gpoll1627199990'  id='choice_9_16_0'    \/>\n\t\t\t\t<label for='choice_9_16_0' id='label_9_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_9_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='gpoll1695c12d87'  id='choice_9_16_1'    \/>\n\t\t\t\t<label for='choice_9_16_1' id='label_9_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_9\"]){return false;}  if( !jQuery(\"#gform_9\")[0].checkValidity || jQuery(\"#gform_9\")[0].checkValidity()){window[\"gf_submitting_9\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_9\"]){return false;} if( !jQuery(\"#gform_9\")[0].checkValidity || jQuery(\"#gform_9\")[0].checkValidity()){window[\"gf_submitting_9\"]=true;}  jQuery(\"#gform_9\").trigger(\"submit\",[true]); 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