OpenStruct.new(
benefits_type: {
enrollment: 'F[0].P4[0].CheckBox7[6]',
registration: 'F[0].P4[0].CheckBox7[7]'
},
veteran: {
name: 'F[0].P4[0].LastFirstMiddle[0]',
preferred_name: 'F[0].P4[0].TextField2[1]',
mothers_maiden_name: 'F[0].P4[0].TextField2[0]',
date_of_birth: 'F[0].P4[0].DateTimeField4[0]',
gender: 'F[0].P4[0].RadioButtonList[1]',
sigi_genders: 'F[0].P4[0].RadioButtonList[4]',
ssn: 'F[0].P4[0].SSN[0]',
place_of_birth: 'F[0].P4[0].TextField5[0]',
state_of_birth: 'F[0].P4[0].TextField5[0]',
marital_status: 'F[0].P4[0].RadioButtonList[3]',
email: 'F[0].P4[0].TextField23[0]',
home_phone: 'F[0].P4[0].TextField10[0]',
mobile_phone: 'F[0].P4[0].TextField11[0]',
initial_va_contact: 'F[0].P4[0].RadioButtonList[2]',
address: {
street: 'F[0].P4[0].TextField6[0]',
city: 'F[0].P4[0].TextField7[0]',
state: 'F[0].P4[0].TextField8[0]',
postalCode: 'F[0].P4[0].TextField25[0]'
},
home_address: {
street: 'F[0].P4[0].TextField6[1]',
city: 'F[0].P4[0].TextField7[1]',
state: 'F[0].P4[0].TextField8[1]',
postalCode: 'F[0].P4[0].TextField25[1]'
},
ethnicity: {
isAmericanIndianOrAlaskanNative: 'F[0].P4[0].CheckBox7[0]',
isAsian: 'F[0].P4[0].CheckBox7[1]',
isBlackOrAfricanAmerican: 'F[0].P4[0].CheckBox7[3]',
isSpanishHispanicLatino: 'F[0].P4[0].RadioButtonList[0]',
isNativeHawaiianOrOtherPacificIslander: 'F[0].P4[0].CheckBox7[4]',
isWhite: 'F[0].P4[0].CheckBox7[2]',
hasDemographicNoAnswer: 'F[0].P4[0].CheckBox7[5]'
},
service: {
last_branch_of_service: 'F[0].P5[0].TextField13[0]',
last_entry_date: 'F[0].P5[0].DateTimeField8[0]',
last_discharge_date: 'F[0].P5[0].DateTimeField9[0]',
discharge_type: 'F[0].P5[0].TextField24[0]',
purple_heart_recipient: 'F[0].P5[0].RadioButtonList[6]',
is_former_pow: 'F[0].P5[0].RadioButtonList[7]',
post_11111998_combat: 'F[0].P5[0].RadioButtonList[8]',
disabled_in_lod: 'F[0].P5[0].RadioButtonList[9]',
sw_asia_combat: 'F[0].P5[0].RadioButtonList[10]',
vietnam_service: 'F[0].P5[0].RadioButtonList[12]',
exposed_to_radiation: 'F[0].P5[0].RadioButtonList[13]',
radium_treatments: 'F[0].P5[0].RadioButtonList[14]',
camp_lejeune: 'F[0].P5[0].RadioButtonList[15]'
},
disclose_financial_information: 'F[0].P6[0].RadioButtonList[0]',
gross_income: 'F[0].P6[0].NumericField2[0]',
net_income: 'F[0].P6[0].NumericField2[3]',
other_income: 'F[0].P6[0].NumericField2[6]'
},
spouse: {
name: 'F[0].P5[0].TextField20[0]',
date_of_birth: 'F[0].P5[0].DateTimeField6[0]',
date_of_marriage: 'F[0].P5[0].DateTimeField5[0]',
address: 'F[0].P5[0].TextField20[3]',
cohabitated_last_year: 'F[0].P5[0].RadioButtonList[2]',
gross_income: 'F[0].P6[0].NumericField2[1]',
net_income: 'F[0].P6[0].NumericField2[4]',
other_income: 'F[0].P6[0].NumericField2[7]'
},
is_medicaid_eligible: 'F[0].P5[0].RadioButtonList[4]',
is_enrolled_nedicare_part_a: 'F[0].P5[0].RadioButtonList[5]',
medicare_number: 'F[0].P5[0].MedicareClaimNumber[0]',
medicare_effective_date: 'F[0].P5[0].DateTimeField1[0]',
deductible_medical_expenses: 'F[0].P6[0].NumericField2[9]',
deductible_funeral_expenses: 'F[0].P6[0].NumericField2[10]',
deductible_education_expenses: 'F[0].P6[0].NumericField2[11]',
providers: {
insurance_name: 'F[0].P5[0].TextField17[0]',
insurance_policy_holder_name: 'F[0].P5[0].TextField18[0]',
insurance_policy_number: 'F[0].P5[0].TextField19[0]',
insurance_group_code: 'F[0].P5[0].TextField19[1]'
},
dependents: {
name: 'F[0].P5[0].TextField20[1]',
date_of_birth: 'F[0].P5[0].DateTimeField3[0]',
ssn: 'F[0].P5[0].TextField20[4]',
relation: 'F[0].P5[0].RadioButtonList[3]',
became_dependent: 'F[0].P5[0].DateTimeField7[0]',
attend_school_last_year: 'F[0].P5[0].RadioButtonList[1]',
disabled_before18: 'F[0].P5[0].RadioButtonList[0]',
gross_income: 'F[0].P6[0].NumericField2[2]',
net_income: 'F[0].P6[0].NumericField2[5]',
other_income: 'F[0].P6[0].NumericField2[8]'
}
)