This form is for data gathering purposes only. Do not ask questions here.

    This is a survey form. Please do not ask questions here.

    [md-form]
    [md-text label="Facility name"]

    [/md-text]

    [md-select label="Type of facility"]

    [/md-select]

    [group group-bite clear_on_hide]

    [md-checkbox label="Select days of operation." display="inline"]
    Mon-FriSatSun
    [/md-checkbox]

    [/group]

    [group group-hiv-std clear_on_hide]

    [md-checkbox label="Select days of operation." display="inline"]
    Mon-FriSatSun
    [/md-checkbox]

    [md-radio label="Select class of facility." display="inline"]
    PrivateGovNGOOthers
    [/md-radio]

    [md-checkbox label="Select available treatment." display="inline"]
    PrEPPEP
    [/md-checkbox]

    [md-radio label="Is HIV testing available to non-locals?" display="inline"]
    YesNo
    [/md-radio]

    [md-checkbox label="Select all available tests."]
    HIVGonorrhea / ChlamydiaSyphilis (VDRL)Hepatitis B (HBsAg)Herpes
    [/md-checkbox]

    [md-checkbox label="Select all available vaccines."]
    FluPREVENAR13PneumoHep AHep BMeningoHPVPolioJap EncephDPTTyphoid
    [/md-checkbox]

    [/group]

    [group group-hotel clear_on_hide]

    [md-radio label="Is short-time available?" display="inline"]
    YesNo
    [/md-radio]

    [group group-short-time-yes clear_on_hide]
    [md-text label="How much is 3 hrs?"]

    [/md-text]

    [md-text label="How much is 12 hrs?"]

    [/md-text]
    [/group]

    [md-radio label="Is reservation accepted here?" display="inline"]
    YesNo
    [/md-radio]

    [group group-reservation-yes clear_on_hide]
    [md-text label="How to reserve a room?"]

    [/md-text]
    [/group]

    [/group]

    [group group-lying-in clear_on_hide]

    [md-radio label="Is there a 24-hr service?" display="inline"]
    YesNo
    [/md-radio]

    [md-checkbox label="Select all available offerings."]
    Delivery (Paanak)Pregnancy testPre/Post Natal CareImmunizationNewborn ScreeningNewborn Hearing TestDEPO (DMPA)Family Planning/CounselingPill DispensingI.U.D. InsertionPapsmearBilateral Tubal LigationVasectomyUltrasound
    [/md-checkbox]

    [/group]

    [group group-massage-spa clear_on_hide]

    [md-checkbox label="Select all massage offerings."]
    Shiatsu, Swedish & ThaiDeep TissueLight TouchPocketHot StoneAromatherapySportsTrigger PointReflexologyPrenatalCouple'sChairTwin
    [/md-checkbox]

    [md-checkbox label="Select all available features."]
    Home & Hotel Service24-Hr ServiceAccepts Credit CardsAccepts ReservationsFree Wi-Fi
    [/md-checkbox]

    [/group]

    [md-textarea label="Notes" help="Add notes like operating hrs, fees, landmark, etc."]

    [/md-textarea]

    [md-quiz help="Prove you are a human"]

    [/md-quiz]

    [md-submit][/md-submit]
    [/md-form]