The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

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The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Hepatitis C Link to Care Form

Welcome to Hepatitis C Link to Care

This form is for people who have questions about Hepatitis C testing and treatment, and for anyone who would like help connecting to care for Hepatitis C.

The information you provide on this form is confidential and is collected to help with your Hepatitis C needs.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

First Name

Last Name

Preferred Name (if you have one)

Date of Birth		Preferred Pronouns
Preferred or Primary Language
		What is your race and ethnicity (please select all that apply)

Age

View equation

Do you need an interpreter? (Interpreter services can be arranged for you over the phone at no cost to you.)

Do you need an interpreter? (Interpreter services can be arranged for you over the phone at no cost to you.)

* must provide value

Yes

reset

What do you need help with?

Do you have a mailing address?

	Do you have a phone number?

	Do you have an email address?

Is there another way we can reach you?

What is the best way to contact you?

In order for us to be able to get in touch with you, please provide at least one way to reach you. Thank you!!

Have you ever been tested for hepatitis C?

Do you have a primary healthcare provider?

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Hepatitis C Link to Care Form

First Name

Last Name

Preferred Name (if you have one)

Date of Birth

Preferred Pronouns

Preferred or Primary Language

What is your race and ethnicity (please select all that apply)

What do you need help with?

What do you need help with?

Contact Information

Do you have a mailing address?

Do you have a phone number?

Do you have an email address?

Is there another way we can reach you?

What is the best way to contact you?

What is your phone number?

What is your email address?

In order for us to be able to get in touch with you, please provide at least one way to reach you. Thank you!!

Medical Information

Have you ever been tested for hepatitis C?

Do you have a primary healthcare provider?

What was the result of your hepatitis C test? (If you have been tested more than once, please give the results of your most recent testing)

Who is your primary healthcare provider?

If you have an address (or any other contact information) for your primary healthcare provider, please let us know

You have selected an option that triggers this survey to end right now.