{ "form": { "archived": false, "list_view_fields": [], "public": false, "access": "Private", "connections": [], "created_by_id": "6a0d81350956e3001bd71340", "created_by": { "id": "6a0d81350956e3001bd71340", "first_name": "Ravi", "last_name": "Dutt" }, "owner_id": "6a0d81350956e3001bd71340", "name": "form", "page_count": 3, "current_page": 0, "deployed": true, "created_at": "2026-08-06T06:18:59.976Z", "attributes": { "language_locale_key": "", "is_repeat": false, "is_header_hidden": false, "is_navigation_hidden": false, "enable_sfdc_storage": false, "enable_access_for_community_users": false, "disable_salesforce_offline_sync": false }, "description": "Generic public demo for configuration-only outpatient clinic operational scoring and professional PDF reporting.", "tags": "AI Form Builder, Public Demo, Healthcare, Operational Readiness, Scoring, PDF", "pages": [ { "components": [ { "repeat_value": [], "components": [], "controlling_elements": [], "type": "Paragraph", "name": "Paragraph", "category": "input", "label": "Use this fictional public demo to assess an outpatient clinic location. It demonstrates configurable scoring and reporting only; it is not a regulatory audit or clinical decision tool.", "icon": "/scripts/formbuilder/img/paragraph.png", "component_id": "clinic_intro", "required": false }, { "repeat_value": [], "components": [], "controlling_elements": [], "type": "Text", "name": "Text", "category": "input", "label": "Organization or account", "icon": "/scripts/formbuilder/img/text.png", "component_id": "clinic_organization", "attributes": { "field_label_position": "top" }, "required": true, "value": "Demo Health Network" }, { "repeat_value": [], "components": [], "controlling_elements": [], "type": "Select", "name": "Select", "category": "select", "label": "Clinic location", "icon": "/scripts/formbuilder/img/select.png", "component_id": "clinic_location", "attributes": { "unselected_label": "-- Select --", "remove_none_option": false, "field_label_position": "top" }, "required": true, "value": "Riverside Outpatient Center", "select_options": "Riverside Outpatient Center\nLakeside Family Practice\nNorthpoint Community Clinic" }, { "repeat_value": [], "components": [], "controlling_elements": [], "type": "Text", "name": "Text", "category": "input", "label": "Assessor name", "icon": "/scripts/formbuilder/img/text.png", "component_id": "assessor_name", "attributes": { "field_label_position": "top" }, "required": true, "value": "Jordan Lee" }, { "repeat_value": [], "components": [], "controlling_elements": [], "type": "Date", "name": "Date", "category": "input", "label": "Assessment date", "icon": "/scripts/formbuilder/img/date.png", "component_id": "assessment_date", "attributes": { "format": "YYYY-MM-DD", "field_label_position": "top" }, "required": true, "value": "2026-08-04" }, { "repeat_value": [], "components": [], "controlling_elements": [], "type": "Select", "name": "Select", "category": "select", "label": "Assessment type", "icon": "/scripts/formbuilder/img/select.png", "component_id": "assessment_type", "attributes": { "unselected_label": "-- Select --", "remove_none_option": false, "field_label_position": "top" }, "required": true, "value": "Routine Review", "select_options": "Routine Review\nPre-opening Review\nFollow-up Review" } ], "page_id": "clinic-details", "title": "Clinic Details", "component_count": null, "page_index": null, "deployed": true }, { "components": [ { "repeat_value": [], "components": [], "controlling_elements": [], "type": "Paragraph", "name": "Paragraph", "category": "input", "label": "For each checkpoint, select Yes, No, or N/A. 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assessment below. The Download Professional PDF button exports this exact report layout, without duplicating the form or adding a separate PDF Preview field.", "icon": "/scripts/formbuilder/img/paragraph.png", "component_id": "report_instructions", "required": false }, { "repeat_value": [], "components": [], "controlling_elements": [], "type": "HTML", "name": "HTML", "category": "media", "label": "Clinic Readiness Report", "icon": "/scripts/formbuilder/img/paragraph.png", "component_id": "clinic_readiness_report", "attributes": { "html_edit": "
\n \n\n \n
\n
\n Outpatient Clinic\n
\n\n

\n Operational Readiness Assessment\n

\n\n

\n A concise review of infection prevention, care environment,\n and emergency readiness practices.\n

\n\n \n PUBLIC DEMO\n \n
\n\n \n
\n
\n Assessment details\n
\n\n
\n\n
\n
\n Organization\n
\n
\n {{clinic_organization}}\n
\n
\n\n
\n
\n Clinic location\n
\n
\n {{clinic_location}}\n
\n
\n\n
\n
\n Assessment type\n
\n
\n {{assessment_type}}\n
\n
\n\n
\n
\n Assessor\n
\n
\n {{assessor_name}}\n
\n
\n\n
\n
\n Assessment date\n
\n
\n {{assessment_date}}\n
\n
\n\n
\n
\n Completion\n
\n
\n {{assessment_completion}}\n
\n
\n\n
\n
\n\n \n
\n
\n Overall result\n
\n\n
\n\n
\n
\n {{overall_percentage}}%\n
\n\n
\n {{overall_score}} of {{overall_possible}} applicable points\n
\n
\n\n
\n
\n {{overall_rating}}\n
\n\n \n Operational readiness\n \n\n

\n N/A responses are excluded from the possible-points total\n so the result reflects only applicable checks.\n

\n
\n\n
\n
\n\n \n
\n
\n Domain summary\n
\n\n
\n\n
\n
\n Infection Prevention\n
\n\n
\n {{ip_percentage}}%\n
\n\n
\n {{ip_score}} / {{ip_possible}} applicable points\n
\n
\n\n
\n
\n Care Environment and Equipment\n
\n\n
\n {{ce_percentage}}%\n
\n\n
\n {{ce_score}} / {{ce_possible}} applicable points\n
\n
\n\n
\n
\n Emergency Readiness\n
\n\n
\n {{er_percentage}}%\n
\n\n
\n {{er_score}} / {{er_possible}} applicable points\n
\n
\n\n
\n
\n\n \n
\n
\n Detailed responses\n
\n\n \n \n \n \n \n \n \n \n\n \n\n \n \n \n \n \n\n \n \n \n \n \n\n \n \n \n \n \n\n \n \n \n \n \n\n \n \n \n \n \n\n \n
DomainOperational checkpointResponse
Infection Prevention\n Are hand hygiene supplies readily available in every patient care area?\n {{ip_hand_hygiene}}
Infection Prevention\n Is there a documented process for respiratory hygiene at entry and\n triage points?\n {{ip_respiratory_hygiene}}
Infection Prevention\n Are environmental cleaning responsibilities and schedules clearly assigned?\n {{ip_environmental_cleaning}}
Infection Prevention\n Is reusable patient-care equipment reprocessed between uses according\n to facility procedures?\n {{ip_equipment_reprocessing}}
Care Environment\n Is emergency equipment checked and documented at the required\n facility frequency?\n {{ce_emergency_equipment}}
", "html_detail": "
Outpatient Clinic

Operational Readiness Assessment

A concise review of infection prevention, care environment, and emergency readiness practices.

PUBLIC DEMO
Assessment details
Organization
{{clinic_organization}}
Clinic location
{{clinic_location}}
Assessment type
{{assessment_type}}
Assessor
{{assessor_name}}
Assessment date
{{assessment_date}}
Completion
{{assessment_completion}}
Overall result
{{overall_percentage}}%
{{overall_score}} of {{overall_possible}} applicable points
{{overall_rating}}
Operational readiness

N/A responses are excluded from the possible-points total so the result reflects only applicable checks.

Domain summary
Infection Prevention
{{ip_percentage}}%
{{ip_score}} / {{ip_possible}} applicable points
Care Environment and Equipment
{{ce_percentage}}%
{{ce_score}} / {{ce_possible}} applicable points
Emergency Readiness
{{er_percentage}}%
{{er_score}} / {{er_possible}} applicable points
Detailed responses
DomainOperational checkpointResponse
Infection PreventionAre hand hygiene supplies readily available in every patient care area?{{ip_hand_hygiene}}
Infection PreventionIs there a documented process for respiratory hygiene at entry and triage points?{{ip_respiratory_hygiene}}
Infection PreventionAre environmental cleaning responsibilities and schedules clearly assigned?{{ip_environmental_cleaning}}
Infection PreventionIs reusable patient-care equipment reprocessed between uses according to facility procedures?{{ip_equipment_reprocessing}}
Care EnvironmentIs emergency equipment checked and documented at the required facility frequency?{{ce_emergency_equipment}}
Care EnvironmentAre medication and temperature-sensitive supply storage conditions monitored and documented?{{ce_storage_monitoring}}
Care EnvironmentAre patient information and records protected from unauthorized viewing or access?{{ce_privacy_records}}
Emergency ReadinessDoes the clinic maintain a current, location-specific emergency plan?{{er_current_plan}}
Emergency ReadinessHave staff completed the clinic's emergency training and exercise requirements?{{er_staff_training}}
Emergency ReadinessIs the emergency communication plan current and accessible to staff?{{er_communication_plan}}
Follow-up notes
{{follow_up_notes}}
Recommended next stepReview each item marked No, assign an owner and target date, and retain supporting evidence with the completed assessment.
Scoring method: Yes earns one point, No earns zero points, and N/A is excluded. This fictional public-demo workflow is not a regulatory audit, accreditation instrument, or clinical decision tool.
Generated with Formyoula - Generic public demo{{assessment_date}}
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