[{"question":"Reference Number","answer":"9845938475348573495"},{"question":"Timestamp","answer":"Mon, 16 Mar 2020 02:10:46 PM"},{"question":"Name","answer":"Jolene"},{"question":"Have you travelled since 10 Jan 2020 or do you have travel plans in the next 3 months (up to May 2020)?","answer":"Yes"},{"question":"Country/Territory/region Area","answer":"MALAYSIA"},{"question":"Purpose of Travel:","answer":"Vacation"},{"question":"If you have indicated \"Others\", please provide details, e.g. emergency","answer":""},{"question":"Start Date:","answer":"09 Mar 2020"},{"question":"End Date:","answer":"12 Mar 2020"},{"question":"Transit Country/City Visiting:","answer":""},{"question":"Transit Date:","answer":""},{"question":"Remarks:","answer":""},{"question":"To the best of your knowledge, in the past 14 days, are you or have you been in contact with a Confirmed Case/Suspect Case/Person under Quarantine Order?","answer":"No"},{"question":"I am a:","answer":""},{"question":"How many Confirmed Case/Suspect Case/Person Under Quarantine Order are you in contact of?","answer":""},{"question":"Name of Contact #1:","answer":""},{"question":"Relationship, e.g. sibling or friends:","answer":""},{"question":"who is a","answer":""},{"question":"Date/period of contact:","answer":""},{"question":"Interaction Level:","answer":""},{"question":"Describe level of intensity of contact, eg, transient","answer":""},{"question":"Please provide additional details (e.g. End date of Quarantine Order (QO); If QO, currently well/not well, when test results are available and what is the outcome)","answer":""},{"question":"Name of Contact #2","answer":""},{"question":"Relationship, e.g. sibling or friends","answer":""},{"question":"who is a","answer":""},{"question":"Date/period of contact:","answer":""},{"question":"Interaction Level","answer":""},{"question":"Describe level of intensity of contact, eg, transient","answer":""},{"question":"Please provide additional details (e.g. End date of Quarantine Order (QO); If QO, currently well/not well, when test results are available and what is the outcome)","answer":""},{"question":"Name of Contact #3:","answer":""},{"question":"Relationship, e.g. sibling or friends:","answer":""},{"question":"who is a","answer":""},{"question":"Date/period of contact:","answer":""},{"question":"Interaction Level:","answer":""},{"question":"Describe level of intensity of contact, eg, transient","answer":""},{"question":"Please provide additional details (e.g. End date of Quarantine Order (QO); If QO, currently well/not well, when test results are available and what is the outcome)","answer":""},{"question":"Name of Contact #4:","answer":""},{"question":"Relationship, e.g. sibling or friends:","answer":""},{"question":"who is a","answer":""},{"question":"Date/period of contact:","answer":""},{"question":"Interaction Level:","answer":""},{"question":"Describe level of intensity of contact, eg, transient","answer":""},{"question":"Please provide additional details (e.g. End date of Quarantine Order (QO); If QO, currently well/not well, when test results are available and what is the outcome)","answer":""}]