Jira Service Management

{"xsrfToken":"751deaf2-cee3-42ca-bbaa-02e6d6ea607e_a7033859b5d4ab973761a56fd5dc0cbf62493ee0_lout","branding":{"id":"9","key":"mcr","name":"My Covid Record Support","portalBaseUrl":"/servicedesk/customer/portal/9","logoUrl":"/rest/servicedesk/1/customer/viewport-resources/portal-logo/9/9","theme":{"headerBGColor":"#ffffff","headerLinkColor":"#292929","headerLinkHoverColor":"#021a30","headerLinkHoverBGColor":"#021a30","headerBadgeColor":"#021a30"}},"helpCenterBranding":{"logoUrl":"https://api.media.atlassian.com/file/3936b635-fe7b-42a5-a7cf-f3d3bed4831e/image?token=eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIyYzRiN2U5Ni04YWY5LTQxMTItOTNmZC0wZmE4MzU1MzI2YTQiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpmaWxlOjM5MzZiNjM1LWZlN2ItNDJhNS1hN2NmLWYzZDNiZWQ0ODMxZSI6WyJyZWFkIl19LCJleHAiOjE2ODU5NTE1NjIsIm5iZiI6MTY4NTk1MDk2Mn0.yIGwfgK889Kjgh0aIWxN3KKxF8p7ktVWdFIcIiw-oOM&client=2c4b7e96-8af9-4112-93fd-0fa8355326a4&mode=fit","logoId":"3936b635-fe7b-42a5-a7cf-f3d3bed4831e","isLogoAvailable":true,"helpCenterTitle":"Te Whatu Ora","sharedPortalName":"Te Whatu Ora","userInitialAnnouncementHeader":"","userInitialAnnouncementMessageWiki":"","translations":{"en-GB":{"helpCenterTitle":"Te Whatu Ora","sharedPortalName":"Te Whatu Ora","localeDisplayName":"English (United Kingdom)"}},"canEditAnnouncement":false,"siteDefaultLanguageTag":"en-GB","userLanguageTag":"en-GB","portalThemeColor":"#1a1354","helpCenterTitleColor":"#ffffff","bannerMediaApiUrl":"https://api.media.atlassian.com/file/faa69e5b-fdeb-4ce1-8780-3e17ed65d5ef/image?token=eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIyYzRiN2U5Ni04YWY5LTQxMTItOTNmZC0wZmE4MzU1MzI2YTQiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpmaWxlOmZhYTY5ZTViLWZkZWItNGNlMS04NzgwLTNlMTdlZDY1ZDVlZiI6WyJyZWFkIl19LCJleHAiOjE2ODU5NTE1NjIsIm5iZiI6MTY4NTk1MDk2Mn0.bkXmfw8OW6v7s_o9zx-ZJlmLT2UqMB5xseYNvdlFM0Q&client=2c4b7e96-8af9-4112-93fd-0fa8355326a4&height=300&mode=fit","bannerMediaApiFileId":"faa69e5b-fdeb-4ce1-8780-3e17ed65d5ef","useDefaultBanner":false,"isBannerAvailable":true},"portal":{"id":"9","key":"mcr","projectId":10008,"serviceDeskId":9,"name":"My Covid Record Support","description":"My Covid Record - <a href=\"http://mycovidrecord.health.nz\" class=\"external-link\" rel=\"nofollow noreferrer\" target=\"_blank\">http://mycovidrecord.health.nz</a>","portalBaseUrl":"/servicedesk/customer/portal/9","onlyPortal":false,"reqTypes":[{"id":"200","name":"Make a general enquiry","descriptionHtml":"","callToAction":"Make a general enquiry","introHtml":"If you have an enquiry about your vaccination records, require COVID-19 support or would like to raise a concern, provide us with as much information as you can to let us know how we can help.","icon":10491,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10491","groups":[57],"key":""},{"id":"187","name":"Request a copy of your COVID-19 Vaccination Record","descriptionHtml":"","callToAction":"Request a copy of your COVID-19 Vaccination Record","introHtml":"If you have had a COVID-19 vaccination, you can request a copy of your COVID-19 Vaccination Record. It can be used as evidence of your vaccinations if required by an employer. It cannot be used instead of an International Travel Vaccination Certificate.","icon":10586,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10586","groups":[57],"key":""},{"id":"189","name":"Request a Face Mask Exemption Pass","descriptionHtml":"","callToAction":"Request a Face Mask Exemption Pass","introHtml":"People who have genuine reasons for not being able to wear a face mask can request a personalised Face Mask Exemption Pass.","icon":10587,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10587","groups":[57],"key":""},{"id":"188","name":"Request an International Travel Vaccination Certificate","descriptionHtml":"","callToAction":"Request an International Travel Vaccination Certificate","introHtml":"If you are travelling overseas and need proof of your COVID-19 vaccination status, you need an International Travel Vaccination Certificate. This certificate is available to anyone aged 5 or over who has had any dose of a COVID-19 vaccine in New Zealand.","icon":10584,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10584","groups":[57],"key":""},{"id":"179","name":"Submit overseas vaccine information","descriptionHtml":"","callToAction":"Submit overseas vaccine information","introHtml":"If you had a COVID-19 vaccination overseas, you can provide evidence and details using this form to have these added to the COVID-19 Immunisation Register.","icon":10530,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10530","groups":[57],"key":""},{"id":"186","name":"Updating your information","descriptionHtml":"","callToAction":"Updating your information","introHtml":"Provide us with information of what needs to be updated.","icon":10550,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10550","groups":[57],"key":""},{"id":"77","name":"Ask a question","descriptionHtml":"","callToAction":"Ask a question","introHtml":"Have a question? Submit it here.","icon":10549,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10549","groups":[],"key":""},{"id":"78","name":"Make a general enquiry","descriptionHtml":"","callToAction":"Make a general enquiry","introHtml":"If you have an enquiry about your vaccination records, require COVID-19 support or would like to raise a concern, provide us with as much information as you can to let us know how we can help.","icon":10527,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10527","groups":[],"key":""},{"id":"76","name":"Submit a request or incident","descriptionHtml":"","callToAction":"Submit a request or incident","introHtml":"Submit a request or report a problem.","icon":10540,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10540","groups":[],"key":""}],"reqGroups":[{"id":57,"name":"General"}],"orderMapping":{"57":[200,187,188,179,186,189],"28":[76,77]},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"createPermission":true,"portalAnnouncement":{"portalId":9,"canEditAnnouncement":false,"canAdministerProject":false,"portalProjectKey":"MCR","userLanguageHeader":"Help using My Covid Record","userLanguageMessageWiki":"We will generally respond to your request within 1-2 days. If we are receiving a high number of enquiries, a response could take up to 5 working days. If you need help straightaway, contact our team on 0800 222 478. You can contact us: • Monday, Tuesday, Thursday, and Friday, 8am to 5pm • Wednesday, 9:30am to 5pm • Saturday and Sunday, 9am to 2pm.","defaultLanguageHeader":"Help using My Covid Record","defaultLanguageMessage":"We will generally respond to your request within 1-2 days. If we are receiving a high number of enquiries, a response could take up to 5 working days. If you need help straightaway, contact our team on 0800 222 478.\nYou can contact us:\n•\tMonday, Tuesday, Thursday, and Friday, 8am to 5pm\n•\tWednesday, 9:30am to 5pm\n•\tSaturday and Sunday, 9am to 2pm.","defaultLanguageDisplayName":"English (United Kingdom)","isUsingLanguageSupport":false,"translations":{}},"canViewCreateRequestForm":true,"isProjectSimplified":false},"reqCreate":{"id":179,"projectId":10008,"form":{"name":"Submit overseas vaccine information","descriptionHtml":"","callToAction":"Submit overseas vaccine information","intro":"If you had a COVID-19 vaccination overseas, you can provide evidence and details using this form to have these added to the COVID-19 Immunisation Register.","instructions":"","icon":10530,"iconUrl":"https://moh-c19-support.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/10530","key":""},"fields":[{"fieldType":"text","fieldId":"email","fieldConfigId":"","label":"Email confirmation to","description":"","descriptionHtml":"","required":true,"displayed":true,"presetValues":[]},{"fieldType":"attachment","fieldId":"attachment","fieldConfigId":"","label":"Attachment","description":"","descriptionHtml":"","required":false,"displayed":true,"presetValues":[]},{"fieldType":"text","fieldId":"summary","fieldConfigId":"","label":"Summary","description":"","descriptionHtml":"","required":true,"displayed":false,"presetValues":["Overseas Vaccine Submission"]},{"fieldType":"multiselect","fieldId":"components","fieldConfigId":"","label":"Components","description":"","descriptionHtml":"","required":false,"displayed":false,"presetValues":["10108"],"values":[{"value":"10175","label":"3rd Dose","selected":false,"children":[]},{"value":"10124","label":"Account Delete","selected":false,"children":[]},{"value":"10197","label":"Address Change","selected":false,"children":[]},{"value":"10388","label":"Bookings","selected":false,"children":[]},{"value":"10231","label":"Business Enquiry","selected":false,"children":[]},{"value":"10373","label":"Case Investigation Support","selected":false,"children":[]},{"value":"10229","label":"Certificate Request","selected":false,"children":[]},{"value":"10123","label":"Child Query","selected":false,"children":[]},{"value":"10149","label":"CPIM Issue","selected":false,"children":[]},{"value":"10151","label":"Data Fix","selected":false,"children":[]},{"value":"10227","label":"Email","selected":false,"children":[]},{"value":"10113","label":"Enhancement Requests","selected":false,"children":[]},{"value":"10228","label":"Exemption Request","selected":false,"children":[]},{"value":"10119","label":"Feedback","selected":false,"children":[]},{"value":"10199","label":"Forms","selected":false,"children":[]},{"value":"10110","label":"General Enquiry","selected":false,"children":[]},{"value":"10107","label":"ID Validation Issues","selected":false,"children":[]},{"value":"10237","label":"Identification","selected":false,"children":[]},{"value":"10118","label":"Incorrect Information","selected":false,"children":[]},{"value":"10086","label":"Intranet","selected":false,"children":[]},{"value":"10443","label":"ITC","selected":false,"children":[]},{"value":"10085","label":"Jira","selected":false,"children":[]},{"value":"10215","label":"Level 3","selected":false,"children":[]},{"value":"10387","label":"Mask Exemption","selected":false,"children":[]},{"value":"10180","label":"MCR Issues","selected":false,"children":[]},{"value":"10239","label":"MCR Test Results","selected":false,"children":[]},{"value":"10220","label":"Missing Dose","selected":false,"children":[]},{"value":"10393","label":"MVP 1.1 Feedback","selected":false,"children":[]},{"value":"10391","label":"MVP 1.1 Query","selected":false,"children":[]},{"value":"10181","label":"Name Issues","selected":false,"children":[]},{"value":"10109","label":"NHI Issues","selected":false,"children":[]},{"value":"10121","label":"No ID","selected":false,"children":[]},{"value":"10484","label":"NZ ITC","selected":false,"children":[]},{"value":"10108","label":"Overseas Vaccination","selected":false,"children":[]},{"value":"10242","label":"Overseas Vaccination Bulk reply","selected":false,"children":[]},{"value":"10234","label":"Pass Issues","selected":false,"children":[]},{"value":"10212","label":"Phone Number Issues","selected":false,"children":[]},{"value":"10377","label":"Proof of recovery","selected":false,"children":[]},{"value":"10087","label":"Public website","selected":false,"children":[]},{"value":"10375","label":"RAT Backdate Requests","selected":false,"children":[]},{"value":"10280","label":"RAT Test","selected":false,"children":[]},{"value":"10485","label":"RAT Upon Arrival","selected":false,"children":[]},{"value":"10120","label":"RealMe Issues","selected":false,"children":[]},{"value":"10374","label":"RedCap Forms","selected":false,"children":[]},{"value":"10122","label":"Registration Issues","selected":false,"children":[]},{"value":"10185","label":"Security","selected":false,"children":[]},{"value":"10183","label":"Shared Email","selected":false,"children":[]},{"value":"10390","label":"Tracer","selected":false,"children":[]},{"value":"10179","label":"Vax Letters","selected":false,"children":[]},{"value":"10100","label":"Verification Code Issues","selected":false,"children":[]}]}],"userOrganisations":[],"canBrowseUsers":false,"requestCreateBaseUrl":"/servicedesk/customer/portal/9/create/179","requestValidateBaseUrl":"/servicedesk/customer/portal/9/validate/179","calendarParams":{"firstDay":1,"date":"2023-06-05T19:42:42+1200","useISO8601WeekNumbers":false,"dateIfFormat":"%e/%b/%y","dateTimeIfFormat":"%e/%b/%y %I:%M %p","timeFormat":"12"},"kbs":{"kbEnabled":false,"serviceDeskId":-1},"canRaiseOnBehalf":false,"canSignupCustomers":false,"canCreateAttachments":true,"attachmentRequiredField":false,"hasGroups":true,"canSubmitWithEmailAddress":false,"showRecaptcha":true,"siteKey":"6LePXLkdAAAAAF4gCNalrL1IvZcqbNbZf_Zakudd","mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIyYzRiN2U5Ni04YWY5LTQxMTItOTNmZC0wZmE4MzU1MzI2YTQiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpjb2xsZWN0aW9uOnVwbG9hZC1wcm9qZWN0LTEwMDA4IjpbInJlYWQiLCJjcmVhdGUiLCJ1cGRhdGUiXSwidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y2h1bms6KiI6WyJyZWFkIiwiY3JlYXRlIl19LCJleHAiOjE2ODU5NTIxNjIsIm5iZiI6MTY4NTk1MDk2Mn0.WNBn3OZ2JkagC1aY7SQr9e265Mjquha6OXUoo_5tF2M","targetCollection":"upload-project-10008","endpointUrl":"https://api.media.atlassian.com","clientId":"2c4b7e96-8af9-4112-93fd-0fa8355326a4","tokenDurationInMins":20},"hasProformaForm":true,"proformaTemplateForm":{"id":1,"updated":"2023-05-09T04:39:24.586156Z","publish":{"jira":{"newIssueIssueTypeIds":[],"newIssueRequestTypeIds":[179],"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[179],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":1,"name":"Submit overseas vaccine information","submit":{"lock":false,"pdf":false},"language":"en-GB"},"layout":[{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Providing proof of overseas COVID-19 vaccinations","marks":[{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"You need to provide evidence of your overseas vaccinations with this form to have your overseas COVID-19 vaccinations recorded against your New Zealand National Health Index (NHI) number."}]},{"type":"paragraph","content":[{"type":"text","text":"This must be provided as a vaccination record or digital certificate, and show:"}]},{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"Your first and last name"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"The vaccine name"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"The date you had the vaccines"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"The country where you had the vaccines."}]}]}]},{"type":"paragraph","content":[{"type":"text","text":"Your vaccination records must be in English, or professionally translated into English before you apply."}]},{"type":"paragraph","content":[{"type":"text","text":"Click here to read the Te Whatu Ora privacy statement","marks":[{"type":"link","attrs":{"href":"https://www.tewhatuora.govt.nz/about-our-site/privacy-and-security"}},{"type":"underline"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":1},"localId":"207241e2-f7c4-4603-94e9-456ca45a285c"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":35},"localId":"f5023e35-8045-435a-8c8b-782ebbcfbfaf"}},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Details of the person this request is for","marks":[{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"These details must match the details on the proof of vaccination."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":4},"localId":"580b0acb-e8fb-4d94-85c9-da9749cd8f2d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":5},"localId":"df302674-2b49-4d65-aab4-b73bd92e0aed"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":6},"localId":"c0c4b68d-0afd-484d-85c0-821414f7f5c4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":7},"localId":"d6545858-361e-4783-bbf6-bcdddb153aec"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":30},"localId":"81158ac3-505c-40ed-87b0-36f0099f139a"}},{"type":"paragraph","content":[{"type":"text","text":"Follow"},{"type":"text","text":" ","marks":[{"type":"link","attrs":{"href":"https://www.health.govt.nz/our-work/health-identity/national-health-index/nhi-information-health-consumers/national-health-index-questions-and-answers#bwhatis"}}]},{"type":"text","text":"this link","marks":[{"type":"link","attrs":{"href":"https://www.health.govt.nz/our-work/health-identity/national-health-index/nhi-information-health-consumers/national-health-index-questions-and-answers#bwhatis"}},{"type":"textColor","attrs":{"color":"#0747a6"}},{"type":"underline"}]},{"type":"text","text":" for more information on NHI numbers."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":31},"localId":"d7834b5e-612b-4a99-b7f9-7fb56b60ba2e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":32},"localId":"31753299-1576-4b7d-9ea7-35e724a1cc4a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":33},"localId":"a5e78331-1102-44de-857e-6a8033d47c9d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":8},"localId":"f836c72e-287c-4947-a171-04c9bedae05e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":9},"localId":"a048ba9b-635f-4813-a15e-59490fa40a7a"}}]},{"version":1,"type":"doc","content":[{"type":"rule"},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Add your vaccine dosage details","marks":[{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"Enter evidence and details of each dose of the COVID-19 vaccine you had overseas."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":15},"localId":"79a54697-818d-42f1-9137-e327e3eb36f0"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":36},"localId":"ede2c0f3-a55c-4253-81d7-8eb8084fb3b5"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":17},"localId":"a5e5295d-9e65-458a-87f2-351256a81eeb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":18},"localId":"e8a4a46b-8954-4f8c-8dd0-c40d719028e6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":19},"localId":"831565a7-88c6-46f6-a99c-35bc29d55ebd"}}]},{"version":1,"type":"doc","content":[{"type":"rule"},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":20},"localId":"b4a2f214-d9cc-4660-97f4-7c99d9a989bb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":22},"localId":"013c9e9d-203b-4a92-85e1-3367f274e605"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":23},"localId":"3381b0eb-6aab-4b23-b79e-044c2c58a544"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":24},"localId":"2dc47891-c420-46a9-b7ae-86a15ca31172"}}]},{"version":1,"type":"doc","content":[{"type":"rule"},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":64},"localId":"05b5699e-89b8-4446-85c3-73b206a0f541"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":27},"localId":"6e66a4d9-c10e-4a4b-ba4c-16d8ff249726"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":28},"localId":"58c4070b-4557-4340-8667-81a1450b190e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":29},"localId":"95d9c1f8-6cc9-4dfd-80be-7fcc7ed7e53a"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":65},"localId":"932297ab-fb40-4c99-a909-28da84f8155d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":38},"localId":"7f4fa806-0fd1-4972-aea9-4da3d98f4e3c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":39},"localId":"3e1b6c8d-6826-472c-9c9a-a48b235f444d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":40},"localId":"620919cb-2a06-40bb-886d-0324c68a776f"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":66},"localId":"def054b0-b2d1-4af3-bff1-1858f15c9211"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":44},"localId":"58eac5b2-f3f3-4e46-9594-95419fb0e05f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":47},"localId":"bcc5ed1f-a498-47a9-8fba-e0b8c7964724"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":46},"localId":"d94e529b-18b8-4b17-98fe-8153e2679630"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":67},"localId":"bca72e7f-f0de-426e-bd30-4fbf95e70eda"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":49},"localId":"1ab7a6c0-5be7-4a31-886a-bf7b944d382a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":50},"localId":"f970ff0c-1786-4102-9abe-32fc24a37e6a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":51},"localId":"3ec5ea5e-6c46-45ad-b397-347d6e690b00"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":3},"content":[{"type":"text","text":"Upload records for this vaccination.","marks":[{"type":"strong"},{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"You must provide documents as a vaccination record or digital certificate that displays your first and last name, the vaccine names, the dates you had the vaccines and the country where you had the vaccines. Personal details must match the details you have provided in this form. Records must be in English or professionally translated into English before you apply."}]},{"type":"panel","attrs":{"panelType":"warning"},"content":[{"type":"paragraph","content":[{"type":"text","text":"To add an attachment, go back to the top of this page."}]}]},{"type":"paragraph","content":[]}]}],"conditions":{"59":{"t":"sh","i":{"co":{"cIds":{"15":["6"]}}},"o":{"sIds":["8"]}},"57":{"t":"sh","i":{"co":{"cIds":{"15":["4","5","6"]}}},"o":{"sIds":["6"]}},"58":{"t":"sh","i":{"co":{"cIds":{"15":["5","6"]}}},"o":{"sIds":["7"]}},"56":{"t":"sh","i":{"co":{"cIds":{"15":["3","4","5","6"]}}},"o":{"sIds":["5"]}},"55":{"t":"sh","i":{"co":{"cIds":{"15":["2","3","4","5","6"]}}},"o":{"sIds":["4"]}}},"sections":{"8":{"conditions":["59"]},"4":{"conditions":["55"]},"9":{"conditions":[]},"5":{"conditions":["56"]},"2":{"conditions":[]},"7":{"conditions":["58"]},"3":{"conditions":[]},"6":{"conditions":["57"]},"1":{"conditions":[]}},"questions":{"67":{"type":"cd","label":"Name of sixth vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"8":{"type":"pg","label":"Current residential address ","description":"This will help us find your records.","validation":{"rq":true},"jiraField":"customfield_10089","questionKey":""},"22":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10081","questionKey":""},"50":{"type":"cd","label":"Country or jurisdiction where vaccine administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10980","label":"Taiwan","other":false},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10758","label":"Tonga"},{"id":"10976","label":"Tokelau"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"46":{"type":"cs","label":"Fifth dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"5":{"type":"tl","label":"Middle name","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"17":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10079","questionKey":""},"64":{"type":"cd","label":"Name of third vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"38":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10113","questionKey":""},"18":{"type":"cd","label":"Country or jurisdiction where you had your vaccine.","description":"","validation":{"rq":true},"jiraField":"customfield_10080","questionKey":""},"29":{"type":"cs","label":"Third dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"28":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10976","label":"Tokelau"},{"id":"10758","label":"Tonga"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"66":{"type":"cd","label":"Name of fifth vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"51":{"type":"cs","label":"Sixth dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"19":{"type":"cs","label":"Type of dose?","description":"For most people, and most COVID-19 vaccines, a primary course is the first 2 doses of the vaccine. For Janssen (Johnson & Johnson) or another single dose vaccine, the primary course is 1 dose. Boosters are not part of a primary course. Severely immunocompromised people may get extra doses of the COVID-19 vaccine. In New Zealand, these are considered part of the primary course, not boosters.","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"23":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"jiraField":"customfield_10082","questionKey":""},"4":{"type":"tl","label":"First name","description":"","validation":{"rq":true},"jiraField":"customfield_10073","questionKey":""},"40":{"type":"cs","label":"Fourth dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"15":{"type":"cd","label":"How many doses of COVID-19 vaccine received overseas need to be recorded?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"1","other":false},{"id":"2","label":"2","other":false},{"id":"3","label":"3","other":false},{"id":"4","label":"4","other":false},{"id":"5","label":"5","other":false},{"id":"6","label":"6","other":false}],"questionKey":""},"9":{"type":"pg","label":"Last known residential address in New Zealand","description":"If your current address is different to what you have recorded against your NHI this will help us find your records. ","validation":{"rq":false},"choices":[],"questionKey":""},"44":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10114","questionKey":""},"33":{"type":"tl","label":"Contact phone number","description":"Use a mobile number if you can. This can be a New Zealand or international phone number. If entering an international number, include the country code (such as +61 for Australia).","validation":{"rq":false,"rgx":{"p":"[^A-Za-z]","m":"Alpha Characters are not allowed"}},"jiraField":"customfield_10118","questionKey":""},"24":{"type":"cs","label":"Second dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"35":{"type":"cs","label":"Who are you filling this form out for? ","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Myself","other":false},{"id":"2","label":"Someone else (with their consent)","other":false}],"questionKey":""},"65":{"type":"cd","label":"Name of fourth vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"32":{"type":"te","label":"Confirm email","description":"","validation":{"rq":true},"jiraField":"customfield_10110","questionKey":""},"49":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10115","questionKey":""},"6":{"type":"tl","label":"Last name","description":"","validation":{"rq":false},"jiraField":"customfield_10074","questionKey":""},"36":{"type":"cd","label":"Name of vaccine","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"jiraField":"customfield_10077","questionKey":""},"1":{"type":"cm","label":"I have read this privacy statement and understand how the information I provide will be used.","description":"","validation":{"rq":true,"ch":"1"},"choices":[{"id":"1","label":"Accept and continue","other":false}],"questionKey":""},"39":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10758","label":"Tonga"},{"id":"10976","label":"Tokelau"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"47":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10758","label":"Tonga"},{"id":"10976","label":"Tokelau"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"31":{"type":"te","label":"Email","description":"This should be the email address you want us to use to contact you about your request.","validation":{"rq":true},"jiraField":"customfield_10109","questionKey":""},"20":{"type":"cd","label":"Name of second vaccine dose","description":"","validation":{"rq":true},"jiraField":"customfield_10078","questionKey":""},"27":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10112","questionKey":""},"30":{"type":"tl","label":"National Health Index (NHI) number","description":"If you have received medical care in New Zealand before, you will have an NHI number. Providing your NHI is optional. It will help us find your records and will be used to record your COVID-19 vaccinations. You can find your NHI on a prescription or prescription receipt, a prescription medicine label, a hospital letter, an x-ray or test result, or your online patient portal.","validation":{"rq":false,"mxc":10,"rgx":{"p":"[A-Za-z0-9]+","m":"NHI numbers are usually in one of the following formats; 3 letters, 4 numbers (e.g. ABC1234), or 3 letters, 2 numbers, 2 letters (e.g. ABC12DE)."}},"jiraField":"customfield_10083","questionKey":""},"7":{"type":"da","label":"Date of Birth","description":"","validation":{"rq":true},"jiraField":"customfield_10076","questionKey":""}}}},"proforma":{"formExists":true,"formValid":true,"formTemplateData":{"id":1,"updated":"2023-05-09T04:39:24.586156Z","publish":{"jira":{"newIssueIssueTypeIds":[],"newIssueRequestTypeIds":[179],"submitOnCreate":true,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[179],"submitOnCreate":true,"validateOnCreate":true}},"design":{"settings":{"templateId":1,"name":"Submit overseas vaccine information","submit":{"lock":false,"pdf":false},"language":"en-GB"},"layout":[{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Providing proof of overseas COVID-19 vaccinations","marks":[{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"You need to provide evidence of your overseas vaccinations with this form to have your overseas COVID-19 vaccinations recorded against your New Zealand National Health Index (NHI) number."}]},{"type":"paragraph","content":[{"type":"text","text":"This must be provided as a vaccination record or digital certificate, and show:"}]},{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"Your first and last name"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"The vaccine name"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"The date you had the vaccines"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"type":"text","text":"The country where you had the vaccines."}]}]}]},{"type":"paragraph","content":[{"type":"text","text":"Your vaccination records must be in English, or professionally translated into English before you apply."}]},{"type":"paragraph","content":[{"type":"text","text":"Click here to read the Te Whatu Ora privacy statement","marks":[{"type":"link","attrs":{"href":"https://www.tewhatuora.govt.nz/about-our-site/privacy-and-security"}},{"type":"underline"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":1},"localId":"207241e2-f7c4-4603-94e9-456ca45a285c"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":35},"localId":"f5023e35-8045-435a-8c8b-782ebbcfbfaf"}},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Details of the person this request is for","marks":[{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"These details must match the details on the proof of vaccination."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":4},"localId":"580b0acb-e8fb-4d94-85c9-da9749cd8f2d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":5},"localId":"df302674-2b49-4d65-aab4-b73bd92e0aed"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":6},"localId":"c0c4b68d-0afd-484d-85c0-821414f7f5c4"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":7},"localId":"d6545858-361e-4783-bbf6-bcdddb153aec"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":30},"localId":"81158ac3-505c-40ed-87b0-36f0099f139a"}},{"type":"paragraph","content":[{"type":"text","text":"Follow"},{"type":"text","text":" ","marks":[{"type":"link","attrs":{"href":"https://www.health.govt.nz/our-work/health-identity/national-health-index/nhi-information-health-consumers/national-health-index-questions-and-answers#bwhatis"}}]},{"type":"text","text":"this link","marks":[{"type":"link","attrs":{"href":"https://www.health.govt.nz/our-work/health-identity/national-health-index/nhi-information-health-consumers/national-health-index-questions-and-answers#bwhatis"}},{"type":"textColor","attrs":{"color":"#0747a6"}},{"type":"underline"}]},{"type":"text","text":" for more information on NHI numbers."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":31},"localId":"d7834b5e-612b-4a99-b7f9-7fb56b60ba2e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":32},"localId":"31753299-1576-4b7d-9ea7-35e724a1cc4a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":33},"localId":"a5e78331-1102-44de-857e-6a8033d47c9d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":8},"localId":"f836c72e-287c-4947-a171-04c9bedae05e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":9},"localId":"a048ba9b-635f-4813-a15e-59490fa40a7a"}}]},{"version":1,"type":"doc","content":[{"type":"rule"},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Add your vaccine dosage details","marks":[{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"Enter evidence and details of each dose of the COVID-19 vaccine you had overseas."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":15},"localId":"79a54697-818d-42f1-9137-e327e3eb36f0"}}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":36},"localId":"ede2c0f3-a55c-4253-81d7-8eb8084fb3b5"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":17},"localId":"a5e5295d-9e65-458a-87f2-351256a81eeb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":18},"localId":"e8a4a46b-8954-4f8c-8dd0-c40d719028e6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":19},"localId":"831565a7-88c6-46f6-a99c-35bc29d55ebd"}}]},{"version":1,"type":"doc","content":[{"type":"rule"},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":20},"localId":"b4a2f214-d9cc-4660-97f4-7c99d9a989bb"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":22},"localId":"013c9e9d-203b-4a92-85e1-3367f274e605"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":23},"localId":"3381b0eb-6aab-4b23-b79e-044c2c58a544"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":24},"localId":"2dc47891-c420-46a9-b7ae-86a15ca31172"}}]},{"version":1,"type":"doc","content":[{"type":"rule"},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":64},"localId":"05b5699e-89b8-4446-85c3-73b206a0f541"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":27},"localId":"6e66a4d9-c10e-4a4b-ba4c-16d8ff249726"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":28},"localId":"58c4070b-4557-4340-8667-81a1450b190e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":29},"localId":"95d9c1f8-6cc9-4dfd-80be-7fcc7ed7e53a"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":65},"localId":"932297ab-fb40-4c99-a909-28da84f8155d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":38},"localId":"7f4fa806-0fd1-4972-aea9-4da3d98f4e3c"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":39},"localId":"3e1b6c8d-6826-472c-9c9a-a48b235f444d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":40},"localId":"620919cb-2a06-40bb-886d-0324c68a776f"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":66},"localId":"def054b0-b2d1-4af3-bff1-1858f15c9211"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":44},"localId":"58eac5b2-f3f3-4e46-9594-95419fb0e05f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":47},"localId":"bcc5ed1f-a498-47a9-8fba-e0b8c7964724"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":46},"localId":"d94e529b-18b8-4b17-98fe-8153e2679630"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":67},"localId":"bca72e7f-f0de-426e-bd30-4fbf95e70eda"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":49},"localId":"1ab7a6c0-5be7-4a31-886a-bf7b944d382a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":50},"localId":"f970ff0c-1786-4102-9abe-32fc24a37e6a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":51},"localId":"3ec5ea5e-6c46-45ad-b397-347d6e690b00"}},{"type":"rule"}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":3},"content":[{"type":"text","text":"Upload records for this vaccination.","marks":[{"type":"strong"},{"type":"textColor","attrs":{"color":"#0747a6"}}]}]},{"type":"paragraph","content":[{"type":"text","text":"You must provide documents as a vaccination record or digital certificate that displays your first and last name, the vaccine names, the dates you had the vaccines and the country where you had the vaccines. Personal details must match the details you have provided in this form. Records must be in English or professionally translated into English before you apply."}]},{"type":"panel","attrs":{"panelType":"warning"},"content":[{"type":"paragraph","content":[{"type":"text","text":"To add an attachment, go back to the top of this page."}]}]},{"type":"paragraph","content":[]}]}],"conditions":{"59":{"t":"sh","i":{"co":{"cIds":{"15":["6"]}}},"o":{"sIds":["8"]}},"57":{"t":"sh","i":{"co":{"cIds":{"15":["4","5","6"]}}},"o":{"sIds":["6"]}},"58":{"t":"sh","i":{"co":{"cIds":{"15":["5","6"]}}},"o":{"sIds":["7"]}},"56":{"t":"sh","i":{"co":{"cIds":{"15":["3","4","5","6"]}}},"o":{"sIds":["5"]}},"55":{"t":"sh","i":{"co":{"cIds":{"15":["2","3","4","5","6"]}}},"o":{"sIds":["4"]}}},"sections":{"8":{"conditions":["59"]},"4":{"conditions":["55"]},"9":{"conditions":[]},"5":{"conditions":["56"]},"2":{"conditions":[]},"7":{"conditions":["58"]},"3":{"conditions":[]},"6":{"conditions":["57"]},"1":{"conditions":[]}},"questions":{"67":{"type":"cd","label":"Name of sixth vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"8":{"type":"pg","label":"Current residential address ","description":"This will help us find your records.","validation":{"rq":true},"jiraField":"customfield_10089","questionKey":""},"22":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10081","questionKey":""},"50":{"type":"cd","label":"Country or jurisdiction where vaccine administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10980","label":"Taiwan","other":false},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10758","label":"Tonga"},{"id":"10976","label":"Tokelau"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"46":{"type":"cs","label":"Fifth dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"5":{"type":"tl","label":"Middle name","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"17":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10079","questionKey":""},"64":{"type":"cd","label":"Name of third vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"38":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10113","questionKey":""},"18":{"type":"cd","label":"Country or jurisdiction where you had your vaccine.","description":"","validation":{"rq":true},"jiraField":"customfield_10080","questionKey":""},"29":{"type":"cs","label":"Third dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"28":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10976","label":"Tokelau"},{"id":"10758","label":"Tonga"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"66":{"type":"cd","label":"Name of fifth vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"51":{"type":"cs","label":"Sixth dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"19":{"type":"cs","label":"Type of dose?","description":"For most people, and most COVID-19 vaccines, a primary course is the first 2 doses of the vaccine. For Janssen (Johnson & Johnson) or another single dose vaccine, the primary course is 1 dose. Boosters are not part of a primary course. Severely immunocompromised people may get extra doses of the COVID-19 vaccine. In New Zealand, these are considered part of the primary course, not boosters.","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"23":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"jiraField":"customfield_10082","questionKey":""},"4":{"type":"tl","label":"First name","description":"","validation":{"rq":true},"jiraField":"customfield_10073","questionKey":""},"40":{"type":"cs","label":"Fourth dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"15":{"type":"cd","label":"How many doses of COVID-19 vaccine received overseas need to be recorded?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"1","other":false},{"id":"2","label":"2","other":false},{"id":"3","label":"3","other":false},{"id":"4","label":"4","other":false},{"id":"5","label":"5","other":false},{"id":"6","label":"6","other":false}],"questionKey":""},"9":{"type":"pg","label":"Last known residential address in New Zealand","description":"If your current address is different to what you have recorded against your NHI this will help us find your records. ","validation":{"rq":false},"choices":[],"questionKey":""},"44":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10114","questionKey":""},"33":{"type":"tl","label":"Contact phone number","description":"Use a mobile number if you can. This can be a New Zealand or international phone number. If entering an international number, include the country code (such as +61 for Australia).","validation":{"rq":false,"rgx":{"p":"[^A-Za-z]","m":"Alpha Characters are not allowed"}},"jiraField":"customfield_10118","questionKey":""},"24":{"type":"cs","label":"Second dose type?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Primary","other":false},{"id":"2","label":"Booster","other":false}],"questionKey":""},"35":{"type":"cs","label":"Who are you filling this form out for? ","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Myself","other":false},{"id":"2","label":"Someone else (with their consent)","other":false}],"questionKey":""},"65":{"type":"cd","label":"Name of fourth vaccine dose","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"choices":[{"id":"10144","label":"Abdala / CIGB-66"},{"id":"11154","label":"Ad5-nCoV-IH/ Convidecia Air"},{"id":"10132","label":"AstraZeneca (Vaxzeria)"},{"id":"11160","label":"Aurora-CoV (EpiVacCorona-N)"},{"id":"11161","label":"Awcorna (Walvax)"},{"id":"11157","label":"Comirnaty Bivalent BA.1 / Pfizer-BioNTech"},{"id":"11130","label":"Comirnaty Bivalent BA.4/BA.5"},{"id":"11135","label":"Corbevax/BECOV2A"},{"id":"10136","label":"CoronaVac (Bharat)"},{"id":"11131","label":"CoronaVac (Sinovac)"},{"id":"10153","label":"COVAX-19/SpikoGen"},{"id":"10137","label":"Covaxin"},{"id":"10150","label":"COVID-19 Inactivated Vaccine/COVIran Barekat"},{"id":"10138","label":"Covidecia / Ad5-nCOV"},{"id":"11136","label":"COVIFENZ"},{"id":"10135","label":"Covilo (Sinopharm -Beijing)"},{"id":"11137","label":"COVIran Barekat (inactivated)"},{"id":"10133","label":"Covishield (Oxford/ AstraZeneca formulation)"},{"id":"11132","label":"Covovax (Novavax formulation)"},{"id":"10146","label":"EpiVacCorona"},{"id":"11138","label":"EpiVacCorona - N"},{"id":"11139","label":"FAKHRAVAC(MIVAC)"},{"id":"11140","label":"Gam-COVID-Vac"},{"id":"11141","label":"GEMCOVAC-19"},{"id":"11153","label":"iNCOVACC"},{"id":"11159","label":"IndoVac"},{"id":"10131","label":"Janssen"},{"id":"10149","label":"KCONVAC / SARS-CoV-2 Vaccine (Vero Cells)"},{"id":"10148","label":"KoviVac"},{"id":"10134","label":"Moderna (Spikevax)"},{"id":"10147","label":"MVC-COV1901"},{"id":"11142","label":"Noora Vaccine"},{"id":"10139","label":"Novavax"},{"id":"10154","label":"Paediatric Pfizer"},{"id":"11134","label":"Pasteurcovac"},{"id":"10130","label":"Pfizer BioNTech COVID-19"},{"id":"10152","label":"QazVac / QazCovid-in"},{"id":"11143","label":"Razi Cov Pars"},{"id":"11144","label":"Recombinant SARS-CoV-2 Vaccine (CHO Cell)"},{"id":"10151","label":"Sinopharm (Wuhan) / WIBP-CorV Inactivated (Vero Cells)"},{"id":"11145","label":"SKYCovione/ GBP510"},{"id":"11146","label":"Soberana 02"},{"id":"11147","label":"Soberana Plus"},{"id":"11156","label":"Spikevax bivalent BA.4/BA.5 (Moderna)"},{"id":"11152","label":"Spikevax bivalent Original/Omicron/ mRNA-1273.214 (Moderna)"},{"id":"10142","label":"Sputnik Light"},{"id":"10140","label":"Sputnik V/ Gam-COVID-Vac"},{"id":"11149","label":"TAK-019 (Novavax formulation)"},{"id":"10143","label":"TAK-919 (Moderna formulation)"},{"id":"11150","label":"Turkovac/ERUCOV-VAC"},{"id":"11155","label":"V-01/ Recombinant SARS-CoV-2 Fusion Protein Vaccine"},{"id":"11133","label":"Valneva (VLA2001)"},{"id":"11158","label":"VidPrevtyn Beta (CoV2 preS dTM adjuvanted vaccine (B.1.351), SP/GSK subunit B.1.351 vaccine)"},{"id":"10145","label":"ZIFIVAX / ZF2001 / RBD-Dimer"},{"id":"10141","label":"ZyCoV-D"}],"questionKey":""},"32":{"type":"te","label":"Confirm email","description":"","validation":{"rq":true},"jiraField":"customfield_10110","questionKey":""},"49":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10115","questionKey":""},"6":{"type":"tl","label":"Last name","description":"","validation":{"rq":false},"jiraField":"customfield_10074","questionKey":""},"36":{"type":"cd","label":"Name of vaccine","description":"The same vaccine might go by different names in different places. For example, the Pfizer/BioNTech vaccine is also called Comirnaty and BNT162b2. If the vaccine is not on this drop down list, then it is not a vaccine type we can add to our register.","validation":{"rq":true},"jiraField":"customfield_10077","questionKey":""},"1":{"type":"cm","label":"I have read this privacy statement and understand how the information I provide will be used.","description":"","validation":{"rq":true,"ch":"1"},"choices":[{"id":"1","label":"Accept and continue","other":false}],"questionKey":""},"39":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10758","label":"Tonga"},{"id":"10976","label":"Tokelau"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"47":{"type":"cd","label":"Country or jurisdiction where vaccine was administered","description":"","validation":{"rq":true},"choices":[{"id":"10580","label":"Afghanistan"},{"id":"10581","label":"Albania"},{"id":"10582","label":"Algeria"},{"id":"10583","label":"Andorra"},{"id":"10584","label":"Angola"},{"id":"10585","label":"Antigua and Barbuda"},{"id":"10586","label":"Argentina"},{"id":"10587","label":"Armenia"},{"id":"10588","label":"Australia"},{"id":"10589","label":"Austria"},{"id":"10590","label":"Azerbaijan"},{"id":"10591","label":"Bahamas"},{"id":"10592","label":"Bahrain"},{"id":"10593","label":"Bangladesh"},{"id":"10594","label":"Barbados"},{"id":"10595","label":"Belarus"},{"id":"10596","label":"Belgium"},{"id":"10597","label":"Belize"},{"id":"10598","label":"Benin"},{"id":"10599","label":"Bhutan"},{"id":"10600","label":"Bolivia"},{"id":"10601","label":"Bosnia and Herzegovina"},{"id":"10602","label":"Botswana"},{"id":"10603","label":"Brazil"},{"id":"10604","label":"Brunei"},{"id":"10605","label":"Bulgaria"},{"id":"10606","label":"Burkina Faso"},{"id":"10607","label":"Burundi"},{"id":"10608","label":"Cabo Verde"},{"id":"10609","label":"Cambodia"},{"id":"10610","label":"Cameroon"},{"id":"10611","label":"Canada"},{"id":"10612","label":"Central African Republic"},{"id":"10613","label":"Chad"},{"id":"10614","label":"Chile"},{"id":"10615","label":"China"},{"id":"10616","label":"Colombia"},{"id":"10617","label":"Comoros"},{"id":"10618","label":"Congo (Congo-Brazzaville)"},{"id":"10619","label":"Cook Islands"},{"id":"10620","label":"Costa Rica"},{"id":"10621","label":"Côte d'Ivoire"},{"id":"10622","label":"Croatia"},{"id":"10623","label":"Cuba"},{"id":"10624","label":"Cyprus"},{"id":"10625","label":"Czechia (Czech Republic)"},{"id":"10626","label":"Democratic Republic of the Congo"},{"id":"10627","label":"Denmark"},{"id":"10628","label":"Djibouti"},{"id":"10629","label":"Dominica"},{"id":"10630","label":"Dominican Republic"},{"id":"10631","label":"Ecuador"},{"id":"10632","label":"Egypt"},{"id":"10633","label":"El Salvador"},{"id":"10634","label":"England"},{"id":"10635","label":"Equatorial Guinea"},{"id":"10636","label":"Eritrea"},{"id":"10637","label":"Estonia"},{"id":"10638","label":"Eswatini (fmr. \"Swaziland\")"},{"id":"10639","label":"Ethiopia"},{"id":"10640","label":"Fiji"},{"id":"10641","label":"Finland"},{"id":"10642","label":"France"},{"id":"10643","label":"Gabon"},{"id":"10644","label":"Gambia"},{"id":"10645","label":"Georgia"},{"id":"10646","label":"Germany"},{"id":"10647","label":"Ghana"},{"id":"10648","label":"Greece"},{"id":"10649","label":"Grenada"},{"id":"10650","label":"Guatemala"},{"id":"10651","label":"Guinea"},{"id":"10652","label":"Guinea-Bissau"},{"id":"10653","label":"Guyana"},{"id":"10654","label":"Haiti"},{"id":"10655","label":"Holy See"},{"id":"10656","label":"Honduras"},{"id":"10657","label":"Hungary"},{"id":"10658","label":"Iceland"},{"id":"10659","label":"India"},{"id":"10660","label":"Indonesia"},{"id":"10661","label":"Iran"},{"id":"10662","label":"Iraq"},{"id":"10663","label":"Ireland"},{"id":"10664","label":"Israel"},{"id":"10665","label":"Italy"},{"id":"10666","label":"Jamaica"},{"id":"10667","label":"Japan"},{"id":"10668","label":"Jordan"},{"id":"10669","label":"Kazakhstan"},{"id":"10670","label":"Kenya"},{"id":"10671","label":"Kiribati"},{"id":"10978","label":"Kosovo"},{"id":"10672","label":"Kuwait"},{"id":"10673","label":"Kyrgyzstan"},{"id":"10674","label":"Laos"},{"id":"10675","label":"Latvia"},{"id":"10676","label":"Lebanon"},{"id":"10677","label":"Lesotho"},{"id":"10678","label":"Liberia"},{"id":"10679","label":"Libya"},{"id":"10680","label":"Liechtenstein"},{"id":"10681","label":"Lithuania"},{"id":"10682","label":"Luxembourg"},{"id":"10683","label":"Madagascar"},{"id":"10684","label":"Malawi"},{"id":"10685","label":"Malaysia"},{"id":"10686","label":"Maldives"},{"id":"10687","label":"Mali"},{"id":"10688","label":"Malta"},{"id":"10689","label":"Marshall Islands"},{"id":"10690","label":"Mauritania"},{"id":"10691","label":"Mauritius"},{"id":"10692","label":"Mexico"},{"id":"10693","label":"Micronesia"},{"id":"10694","label":"Moldova"},{"id":"10695","label":"Monaco"},{"id":"10696","label":"Mongolia"},{"id":"10697","label":"Montenegro"},{"id":"10698","label":"Morocco"},{"id":"10699","label":"Mozambique"},{"id":"10700","label":"Myanmar (formerly Burma)"},{"id":"10701","label":"Namibia"},{"id":"10702","label":"Nauru"},{"id":"10703","label":"Nepal"},{"id":"10704","label":"Netherlands"},{"id":"10705","label":"Nicaragua"},{"id":"10706","label":"Niger"},{"id":"10707","label":"Nigeria"},{"id":"10708","label":"Niue"},{"id":"10709","label":"North Korea"},{"id":"10710","label":"North Macedonia"},{"id":"10711","label":"Norway"},{"id":"10712","label":"Oman"},{"id":"10713","label":"Pakistan"},{"id":"10714","label":"Palau"},{"id":"10715","label":"Palestine State"},{"id":"10716","label":"Panama"},{"id":"10717","label":"Papua New Guinea"},{"id":"10718","label":"Paraguay"},{"id":"10719","label":"Peru"},{"id":"10720","label":"Philippines"},{"id":"10721","label":"Poland"},{"id":"10722","label":"Portugal"},{"id":"10723","label":"Qatar"},{"id":"10724","label":"Romania"},{"id":"10725","label":"Russia"},{"id":"10726","label":"Rwanda"},{"id":"10727","label":"Saint Kitts and Nevis"},{"id":"10728","label":"Saint Lucia"},{"id":"10729","label":"Saint Vincent and the Grenadines"},{"id":"10730","label":"Samoa"},{"id":"10731","label":"San Marino"},{"id":"10732","label":"Sao Tome and Principe"},{"id":"10733","label":"Saudi Arabia"},{"id":"10734","label":"Senegal"},{"id":"10735","label":"Serbia"},{"id":"10736","label":"Seychelles"},{"id":"10737","label":"Sierra Leone"},{"id":"10738","label":"Singapore"},{"id":"10739","label":"Slovakia"},{"id":"10740","label":"Slovenia"},{"id":"10741","label":"Solomon Islands"},{"id":"10742","label":"Somalia"},{"id":"10743","label":"South Africa"},{"id":"10744","label":"South Korea"},{"id":"10745","label":"South Sudan"},{"id":"10746","label":"Spain"},{"id":"10747","label":"Sri Lanka"},{"id":"10748","label":"Sudan"},{"id":"10749","label":"Suriname"},{"id":"10750","label":"Sweden"},{"id":"10751","label":"Switzerland"},{"id":"10752","label":"Syria"},{"id":"10979","label":"Taiwan","other":false},{"id":"10753","label":"Tajikistan"},{"id":"10754","label":"Tanzania"},{"id":"10755","label":"Thailand"},{"id":"10756","label":"Timor-Leste"},{"id":"10757","label":"Togo"},{"id":"10758","label":"Tonga"},{"id":"10976","label":"Tokelau"},{"id":"10759","label":"Trinidad and Tobago"},{"id":"10760","label":"Tunisia"},{"id":"10761","label":"Turkey"},{"id":"10762","label":"Turkmenistan"},{"id":"10763","label":"Tuvalu"},{"id":"10764","label":"Uganda"},{"id":"10765","label":"Ukraine"},{"id":"10766","label":"United Arab Emirates"},{"id":"10767","label":"United Kingdom"},{"id":"10768","label":"United States"},{"id":"10769","label":"Uruguay"},{"id":"10770","label":"Uzbekistan"},{"id":"10771","label":"Vanuatu"},{"id":"10772","label":"Venezuela"},{"id":"10773","label":"Vietnam"},{"id":"10774","label":"Yemen"},{"id":"10775","label":"Zambia"},{"id":"10776","label":"Zimbabwe"}],"questionKey":""},"31":{"type":"te","label":"Email","description":"This should be the email address you want us to use to contact you about your request.","validation":{"rq":true},"jiraField":"customfield_10109","questionKey":""},"20":{"type":"cd","label":"Name of second vaccine dose","description":"","validation":{"rq":true},"jiraField":"customfield_10078","questionKey":""},"27":{"type":"da","label":"Date of vaccination","description":"","validation":{"rq":true},"jiraField":"customfield_10112","questionKey":""},"30":{"type":"tl","label":"National Health Index (NHI) number","description":"If you have received medical care in New Zealand before, you will have an NHI number. Providing your NHI is optional. It will help us find your records and will be used to record your COVID-19 vaccinations. You can find your NHI on a prescription or prescription receipt, a prescription medicine label, a hospital letter, an x-ray or test result, or your online patient portal.","validation":{"rq":false,"mxc":10,"rgx":{"p":"[A-Za-z0-9]+","m":"NHI numbers are usually in one of the following formats; 3 letters, 4 numbers (e.g. ABC1234), or 3 letters, 2 numbers, 2 letters (e.g. ABC12DE)."}},"jiraField":"customfield_10083","questionKey":""},"7":{"type":"da","label":"Date of Birth","description":"","validation":{"rq":true},"jiraField":"customfield_10076","questionKey":""}}}},"linkedJiraFields":["customfield_10080","customfield_10081","customfield_10082","customfield_10083","customfield_10073","customfield_10074","customfield_10076","customfield_10077","customfield_10110","customfield_10089","customfield_10078","customfield_10112","customfield_10079","customfield_10113","customfield_10114","customfield_10115","customfield_10118","customfield_10109"]},"key":""},"portalWebFragments":{"headerPanels":[],"subheaderPanels":[],"footerPanels":[],"pagePanels":{"propertyPanels":[],"legacyPropertyPanels":[]}}}