wotc-form

{ "uischema": { "type": "Categorization", "options": { "variant": "stepper", "showNavButtons": true }, "elements": [ { "type": "Category", "label": "Screening Questions", "elements": [ { "type": "Group", "label": "Applicable Categories", "elements": [ { "type": "VerticalLayout", "elements": [ { "type": "Control", "scope": "#/properties/screening/properties/snap_benefits" }, { "type": "Control", "scope": "#/properties/screening/properties/tanf_benefits" }, { "type": "Control", "scope": "#/properties/screening/properties/ssi_benefit" }, { "type": "Control", "scope": "#/properties/screening/properties/conditional_certification" }, { "type": "Control", "scope": "#/properties/screening/properties/unemployment_comp" }, { "type": "Control", "scope": "#/properties/screening/properties/veteran" }, { "type": "Control", "scope": "#/properties/screening/properties/convicted" }, { "type": "Control", "scope": "#/properties/screening/properties/rural_or_empowerment_zone" }, { "type": "Control", "scope": "#/properties/screening/properties/rehab" } ] } ] } ] }, { "type": "Category", "label": "Snap", "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/screening/properties/snap_benefits", "schema": { "const": true } } }, "elements": [ { "type": "Group", "label": "Tell us more about your SNAP benefits.", "elements": [ { "type": "VerticalLayout", "elements": [ { "type": "Control", "scope": "#/properties/wotc/properties/snap_benefits_extras_name" }, { "type": "Control", "scope": "#/properties/wotc/properties/snap_benefits_before", "label": "How long were you using this benefit?", "options": { "format": "radio" } }, { "type": "Control", "scope": "#/properties/wotc/properties/snap_benefits_extras_city_state" } ] } ] } ] }, { "type": "Category", "label": "Tan-F", "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/screening/properties/tanf_benefits", "schema": { "const": true } } }, "elements": [ { "type": "Group", "label": "Tell us more about your TANF benefits.", "elements": [ { "type": "VerticalLayout", "elements": [ { "type": "Control", "scope": "#/properties/wotc/properties/tanf_benefits_before", "label": "How long were you using this benefit?", "options": { "format": "radio" } }, { "type": "Control", "scope": "#/properties/wotc/properties/tanf_benefits_extras_city_state" } ] } ] } ] }, { "type": "Category", "label": "Unemployment", "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/screening/properties/unemployment_comp", "schema": { "const": true } } }, "elements": [ { "type": "Group", "label": "Tell us more about your unemployment benefits.", "elements": [ { "type": "HorizontalLayout", "elements": [ { "type": "Control", "scope": "#/properties/wotc/properties/unemployment_comp_started" }, { "type": "Control", "scope": "#/properties/wotc/properties/unemployment_comp_city_state" } ] } ] } ] }, { "type": "Category", "label": "Veteran", "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/screening/properties/veteran", "schema": { "const": true } } }, "elements": [ { "type": "Group", "label": "Tell us more about your Veteran benefits.", "elements": [ { "type": "VerticalLayout", "elements": [ { "type": "Control", "scope": "#/properties/wotc/properties/veteran_comp" }, { "type": "Control", "scope": "#/properties/wotc/properties/veteran_compensation", "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/wotc/properties/veteran_comp", "schema": { "const": true } } } }, { "type": "Control", "scope": "#/properties/wotc/properties/veteran_unemployed_6", "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/wotc/properties/veteran_comp", "schema": { "const": true } } } }, { "type": "Control", "scope": "#/properties/wotc/properties/veteran_snap" }, { "type": "HorizontalLayout", "elements": [ { "type": "Control", "scope": "#/properties/wotc/properties/veteran_snap_recipient" }, { "type": "Control", "scope": "#/properties/wotc/properties/veteran_snap_city_state" } ], "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/wotc/properties/veteran_snap", "schema": { "const": true } } } }, { "type": "Control", "scope": "#/properties/wotc/properties/veteran_unemployed", "options": { "format": "radio" } } ] } ] } ] }, { "type": "Category", "label": "Felony", "rule": { "effect": "SHOW", "condition": { "scope": "#/properties/screening/properties/convicted", "schema": { "const": true } } }, "elements": [ { "type": "Group", "label": "Tell us more about your conviction.", "elements": [ { "type": "HorizontalLayout", "elements": [ { "type": "Control", "scope": "#/properties/wotc/properties/convicted_date" }, { "type": "Control", "scope": "#/properties/wotc/properties/convicted_release" } ] }, { "type": "Control", "scope": "#/properties/wotc/properties/convicted_type", "options": { "format": "radio" } } ] } ] }, { "type": "Category", "label": "Personal Info", "elements": [ { "type": "Group", "label": "Personal Information", "elements": [ { "type": "HorizontalLayout", "elements": [ { "type": "Control", "scope": "#/properties/personal/properties/name", "label": "Full Name" }, { "type": "Control", "scope": "#/properties/personal/properties/email", "label": "Email Address" } ] }, { "type": "HorizontalLayout", "elements": [ { "type": "Control", "scope": "#/properties/personal/properties/ssn", "label": "Social Security #" }, { "type": "Control", "scope": "#/properties/personal/properties/dob", "label": "Date of Birth" } ] }, { "type": "HorizontalLayout", "elements": [ { "type": "Control", "scope": "#/properties/personal/properties/phone", "label": "Phone Number" }, { "type": "Control", "scope": "#/properties/personal/properties/mobile_phone", "label": "Cell Phone Number" } ] }, { "type": "HorizontalLayout", "elements": [{ "type": "Control", "scope": "#/properties/personal/properties/address_street", "label": "Street Address" }] }, { "type": "HorizontalLayout", "elements": [ { "type": "Control", "scope": "#/properties/personal/properties/address_city", "label": "City" }, { "type": "Control", "scope": "#/properties/personal/properties/address_state", "label": "State" }, { "type": "Control", "scope": "#/properties/personal/properties/address_postcode", "label": "Zip Code" } ] } ] } ] } ] }, "schema": { "properties": { "screening": { "properties": { "snap_benefits": { "type": "boolean", "title": "I've received SNAP benefits or Food Stamps" }, "tanf_benefits": { "type": "boolean", "title": "I received TANF benefits" }, "ssi_benefit": { "type": "boolean", "title": "I received SSI (Supplemental Security Income) benefits" }, "conditional_certification": { "type": "boolean", "title": "I received a conditional certification from a State Workforce Agency (SWA), or a participating local agency for the Work Opportunity Credit" }, "unemployment_comp": { "type": "boolean", "title": "I've been unemployed for at least 27 consecutive weeks" }, "veteran": { "type": "boolean", "title": "I'm a veteran of the US Armed Forces" }, "convicted": { "type": "boolean", "title": "I've been convicted of a felony" }, "rural_or_empowerment_zone": { "type": "boolean", "title": "I live in a Rural Renewal Community or an Empowerment Zone" }, "rehab": { "type": "boolean", "title": "I received any type of Vocational Rehabilitation services within the past two years" } } }, "wotc": { "properties": { "veteran_comp": { "type": "boolean", "title": "Are you a veteran entitled to compensation for a service-connected disability?" }, "veteran_compensation": { "type": "boolean", "title": "Were you discharged or released from active duty within a year before you were hired?" }, "veteran_unemployed_6": { "type": "boolean", "title": "Where you unemployed for a combined period of at least 6 months (whether or not consecutive) during the year before you were hired?" }, "veteran_snap": { "type": "boolean", "title": "Are you a member of a family that received Supplemental Nutrtion Assistance Program (SNAP) benefits (Food Stamps) for at least 3 months during the 15 months before you were hired?" }, "veteran_unemployed": { "type": "integer", "title": "Were you unemployed for any period before you were hired?", "oneOf": [ { "const": 0, "title": "No" }, { "const": 1, "title": "For less than 6 months" }, { "const": 6, "title": "For More than 6 months" } ] }, "veteran_snap_recipient": { "type": "string", "title": "Who was the primary recipient?" }, "veteran_snap_city_state": { "type": "string", "title": "City / State where benefits received" }, "convicted_date": { "type": "string", "title": "Date of conviction", "format": "date" }, "convicted_release": { "type": "string", "title": "Date of release", "format": "date" }, "convicted_type": { "type": "string", "title": "Type of conviction", "oneOf": [ { "const": "federal", "title": "Federal Conviction" }, { "const": "state", "title": "Stage Conviction" } ] }, "unemployment_comp_started": { "type": "string", "format": "date", "title": "When did your benefits begin?" }, "unemployment_comp_city_state": { "type": "string", "title": "City / State where benefits received" }, "snap_benefits_extras_name": { "type": "string", "title": "Who was the primary recipient?" }, "snap_benefits_before": { "type": "integer", "oneOf": [ { "const": 6, "title": "For the 6 months before you were hired" }, { "const": 3, "title": "For at least 3 of the past 5 months, but you are no longer receiving them" } ] }, "snap_benefits_extras_city_state": { "type": "string", "title": "City / State where benefits received" }, "tanf_benefits_before": { "type": "integer", "oneOf": [ { "const": 9, "title": "For any 9 months during the past 18 months before you were hired" }, { "const": 18, "title": "for any 18 Months beginning after August 5, 1997 and ending within the past 2 years" }, { "const": 2, "title": "your family stopped being eligible within the last 2 years because the law limited the maximum time those payments can be made" } ] }, "tanf_benefits_extras_city_state": { "type": "string", "title": "City / State where benefits received" } } }, "personal": { "properties": { "name": { "type": "string", "minLength": 6, "description": "Please provide your full name" }, "phone": { "type": "string", "minLength": 10 }, "ssn": { "type": "string", "minLength": 9 }, "dob": { "type": "string", "format": "date", "formatMaximum": "2000-01-01" }, "email": { "type": "string" }, "mobile_phone": { "type": "string", "minLength": 10 }, "address_street": { "type": "string" }, "address_city": { "type": "string" }, "address_state": { "type": "string", "oneOf": [ { "const": "AL", "title": "Alabama" }, { "const": "AK", "title": "Alaska" }, { "const": "AZ", "title": "Arizona" }, { "const": "AR", "title": "Arkansas" }, { "const": "CA", "title": "California" }, { "const": "CO", "title": "Colorado" }, { "const": "CT", "title": "Connecticut" }, { "const": "DE", "title": "Delaware" }, { "const": "FL", "title": "Florida" }, { "const": "GA", "title": "Georgia" }, { "const": "HI", "title": "Hawaii" }, { "const": "ID", "title": "Idaho" }, { "const": "IL", "title": "Illinois" }, { "const": "IN", "title": "Indiana" }, { "const": "IA", "title": "Iowa" }, { "const": "KS", "title": "Kansas" }, { "const": "KY", "title": "Kentucky" }, { "const": "LA", "title": "Louisiana" }, { "const": "ME", "title": "Maine" }, { "const": "MD", "title": "Maryland" }, { "const": "MA", "title": "Massachusetts" }, { "const": "MI", "title": "Michigan" }, { "const": "MN", "title": "Minnesota" }, { "const": "MS", "title": "Mississippi" }, { "const": "MO", "title": "Missouri" }, { "const": "MT", "title": "Montana" }, { "const": "NE", "title": "Nebraska" }, { "const": "NV", "title": "Nevada" }, { "const": "NH", "title": "New Hampshire" }, { "const": "NJ", "title": "New Jersey" }, { "const": "NM", "title": "New Mexico" }, { "const": "NY", "title": "New York" }, { "const": "NC", "title": "North Carolina" }, { "const": "ND", "title": "North Dakota" }, { "const": "OH", "title": "Ohio" }, { "const": "OK", "title": "Oklahoma" }, { "const": "OR", "title": "Oregon" }, { "const": "PA", "title": "Pennsylvania" }, { "const": "RI", "title": "Rhode Island" }, { "const": "SC", "title": "South Carolina" }, { "const": "SD", "title": "South Dakota" }, { "const": "TN", "title": "Tennessee" }, { "const": "TX", "title": "Texas" }, { "const": "UT", "title": "Utah" }, { "const": "VT", "title": "Vermont" }, { "const": "VA", "title": "Virginia" }, { "const": "WA", "title": "Washington" }, { "const": "WV", "title": "West Virginia" }, { "const": "WI", "title": "Wisconsin" }, { "const": "WY", "title": "Wyoming" }, { "const": "PR", "title": "Puerto Rico" } ] }, "address_postcode": { "type": "string", "minLength": 5 } }, "required": ["name", "mobile_phone", "phone", "ssn"] } } }, "defaults": { "screening": { "snap_benefits": false, "tanf_benefits": false, "ssi_benefit": false, "veteran": false, "convicted": false, "conditional_certification": false, "unemployment_comp": false, "rural_or_empowerment_zone": false, "rehab": false } }, "data": [] }