{"id":44441,"date":"2021-01-18T07:25:12","date_gmt":"2021-01-18T12:25:12","guid":{"rendered":"http:\/\/ifdresourc.es\/forms\/?page_id=44441"},"modified":"2021-01-18T07:25:13","modified_gmt":"2021-01-18T12:25:13","slug":"ifd-safety-division-injury-report","status":"publish","type":"page","link":"https:\/\/ifdresourc.es\/forms\/hs\/ifd-safety-division-injury-report\/","title":{"rendered":"IFD Safety Division &#8211; Injury Report"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gf_stylespro_wrapper sp_inherit_wrapper' id='gform_wrapper_24' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">IFD Safety Division - Injury Report<\/h2>\n                            <span class='gform_description'>To be used for reporting an injury sustained at work. \r\n<strong>IMPORTANT NOTE:<\/strong> If you are seeking treatment, please stop and contact your Safety Officer who will assist you. If you are just documenting a first report of injury please continue and fill out this form with your information. Thank you!<\/span>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_24' class=' gf_stylespro sp_inherit' action='\/forms\/wp-json\/wp\/v2\/pages\/44441' >\n                        <div class='gform_body gform-body'><div id='gform_fields_24' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_24_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_10' >Date of Injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_24_10' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_24_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_24_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_24_10' class='gform_hidden' value='https:\/\/ifdresourc.es\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_24_71\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Employee Information<\/h3><\/div><div id=\"field_24_73\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\"><label class='gfield_label' for='input_24_73' >Employee Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_24_73' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_16\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\"><label class='gfield_label' for='input_24_16' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_24_16' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_24_16_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_24_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_24_16' class='gform_hidden' value='https:\/\/ifdresourc.es\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_24_17\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\"><label class='gfield_label' for='input_24_17' >Gender<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_24_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/div><fieldset id=\"field_24_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Employee Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_24_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_24_21_1_container' >\n                                        <input type='text' name='input_21.1' id='input_24_21_1' value=''    aria-required='false'    \/>\n                                        <label for='input_24_21_1' id='input_24_21_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_24_21_2_container' >\n                                        <input type='text' name='input_21.2' id='input_24_21_2' value=''     aria-required='false'   \/>\n                                        <label for='input_24_21_2' id='input_24_21_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_24_21_3_container' >\n                                    <input type='text' name='input_21.3' id='input_24_21_3' value=''    aria-required='false'    \/>\n                                    <label for='input_24_21_3' id='input_24_21_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_24_21_4_container' >\n                                        <input type='text' name='input_21.4' id='input_24_21_4' value=''      aria-required='false'    \/>\n                                        <label for='input_24_21_4' id='input_24_21_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_24_21_5_container' >\n                                    <input type='text' name='input_21.5' id='input_24_21_5' value=''    aria-required='false'    \/>\n                                    <label for='input_24_21_5' id='input_24_21_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_24_21_6_container' >\n                                        <select name='input_21.6' id='input_24_21_6'   aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_24_21_6' id='input_24_21_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_24_22\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_22' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_24_22' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_23\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_23' >Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_24_23' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_24\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_24' >Employee Email (@indy.gov)<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_24' id='input_24_24' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_24_25\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Please use your indy.gov email address.<\/h3><\/div><div id=\"field_24_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\"><label class='gfield_label' for='input_24_26' >Rank<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_24_26' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Civilian' >Civilian<\/option><option value='Recruit' >Recruit<\/option><option value='Sub' >Sub<\/option><option value='Private' >Private<\/option><option value='Engineer' >Engineer<\/option><option value='Lieutenant' >Lieutenant<\/option><option value='Captain' >Captain<\/option><option value='Battalion Chief' >Battalion Chief<\/option><option value='Shift Commander' >Shift Commander<\/option><option value='Division Chief' >Division Chief<\/option><option value='Deputy Chief' >Deputy Chief<\/option><option value='Chief of Fire' >Chief of Fire<\/option><\/select><\/div><\/div><div id=\"field_24_27\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\"><label class='gfield_label' for='input_24_27' >Battalion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_24_27' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Admin' >Admin<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><\/select><\/div><\/div><div id=\"field_24_28\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_hidden gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_24_28' >Probationary or Recruit?<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_24_28' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Probationary' >Probationary<\/option><option value='Recruit' >Recruit<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_24_29\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\"><label class='gfield_label' for='input_24_29' >Shift<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_29' id='input_24_29' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='A Shift' >A Shift<\/option><option value='B Shift' >B Shift<\/option><option value='C Shift' >C Shift<\/option><option value='Admin' >Admin<\/option><\/select><\/div><\/div><div id=\"field_24_90\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\"><label class='gfield_label' for='input_24_90' >Work Status When Injury Occurred<\/label><div class='ginput_container ginput_container_select'><select name='input_90' id='input_24_90' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Regular Assignment' >Regular Assignment<\/option><option value='Overtime' >Overtime<\/option><option value='Ride Out' >Ride Out<\/option><option value='Trade Time' >Trade Time<\/option><option value='Temporary Assignment' >Temporary Assignment<\/option><\/select><\/div><\/div><div id=\"field_24_30\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\"><label class='gfield_label' for='input_24_30' >Station Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_24_30' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Station 01' >Station 01<\/option><option value='Station 02' >Station 02<\/option><option value='Station 03' >Station 03<\/option><option value='Station 04' >Station 04<\/option><option value='Station 05' >Station 05<\/option><option value='Station 06' >Station 06<\/option><option value='Station 07' >Station 07<\/option><option value='Station 08' >Station 08<\/option><option value='Station 09' >Station 09<\/option><option value='Station 10' >Station 10<\/option><option value='Station 11' >Station 11<\/option><option value='Station 12' >Station 12<\/option><option value='Station 13' >Station 13<\/option><option value='Station 14' >Station 14<\/option><option value='Station 15' >Station 15<\/option><option value='Station 16' >Station 16<\/option><option value='Station 17' >Station 17<\/option><option value='Station 18' >Station 18<\/option><option value='Station 19' >Station 19<\/option><option value='Station 20' >Station 20<\/option><option value='Station 21' >Station 21<\/option><option value='Station 22' >Station 22<\/option><option value='Station 23' >Station 23<\/option><option value='Station 24' >Station 24<\/option><option value='Station 25' >Station 25<\/option><option value='Station 26' >Station 26<\/option><option value='Station 27' >Station 27<\/option><option value='Station 28' >Station 28<\/option><option value='Station 29' >Station 29<\/option><option value='Station 30' >Station 30<\/option><option value='Station 31' >Station 31<\/option><option value='Station 32' >Station 32<\/option><option value='Station 33' >Station 33<\/option><option value='Station 34' >Station 34<\/option><option value='Station 35' >Station 35<\/option><option value='Station 36' >Station 36<\/option><option value='Station 41' >Station 41<\/option><option value='Station 42' >Station 42<\/option><option value='Station 43' >Station 43<\/option><option value='Station 44' >Station 44<\/option><option value='Station 45' >Station 45<\/option><option value='Station 46' >Station 46<\/option><option value='Station 53' >Station 53<\/option><option value='Station 55' >Station 55<\/option><option value='Admin' >Admin<\/option><\/select><\/div><\/div><fieldset id=\"field_24_31\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_half gf_list_2col o_medium\"  data-field-class=\"gf_half gf_list_2col o_medium\"><legend class='gfield_label gfield_label_before_complex'  >Assignment at Time of Injury<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_24_31'><div class='gchoice gchoice_24_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Engine'  id='choice_24_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_1' id='label_24_31_1'>Engine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='Ladder'  id='choice_24_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_2' id='label_24_31_2'>Ladder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.3' type='checkbox'  value='Squad'  id='choice_24_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_3' id='label_24_31_3'>Squad<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.4' type='checkbox'  value='Boat'  id='choice_24_31_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_4' id='label_24_31_4'>Boat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.5' type='checkbox'  value='TAC'  id='choice_24_31_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_5' id='label_24_31_5'>TAC<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.6' type='checkbox'  value='TSU'  id='choice_24_31_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_6' id='label_24_31_6'>TSU<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.7' type='checkbox'  value='Tanker'  id='choice_24_31_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_7' id='label_24_31_7'>Tanker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.8' type='checkbox'  value='Battalion Car'  id='choice_24_31_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_8' id='label_24_31_8'>Battalion Car<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.9' type='checkbox'  value='Safety Car'  id='choice_24_31_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_9' id='label_24_31_9'>Safety Car<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.11' type='checkbox'  value='EDO'  id='choice_24_31_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_11' id='label_24_31_11'>EDO<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.12' type='checkbox'  value='Admin'  id='choice_24_31_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_12' id='label_24_31_12'>Admin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.13' type='checkbox'  value='Recruit'  id='choice_24_31_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_13' id='label_24_31_13'>Recruit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.14' type='checkbox'  value='Car 10'  id='choice_24_31_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_14' id='label_24_31_14'>Car 10<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.15' type='checkbox'  value='Light Duty'  id='choice_24_31_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_15' id='label_24_31_15'>Light Duty<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_31_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.16' type='checkbox'  value='Task Force'  id='choice_24_31_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_31_16' id='label_24_31_16'>Task Force<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_93\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_93' >Years in the Fire Service<\/label><div class='ginput_container ginput_container_number'><input name='input_93' id='input_24_93' type='text'    value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_24_93\" \/><div class='instruction ' id='gfield_instruction_24_93'>Please enter a number from <strong>1<\/strong> to <strong>50<\/strong>.<\/div><\/div><\/div><div id=\"field_24_32\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Incident Information<\/h3><\/div><div id=\"field_24_33\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_33' >Company officer who I reported this incident to<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_24_33' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_91\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_91' >Company Officer Email (@indy.gov)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_91' id='input_24_91' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_24_94\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_94' >Assigned Battalion Chief Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_24_94' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_95\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_95' >Battalion Chief Email (@indy.gov)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_95' id='input_24_95' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_24_96\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_96' >Additional Battalion Chief Full Name (For example, working over time, ride out BC, Trade Time, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_24_96' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_97\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_97' >Additional Battalion Chief Email (@indy.gov)<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_97' id='input_24_97' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_24_35\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Location of Injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_24_35' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_24_35_1_container' >\n                                        <input type='text' name='input_35.1' id='input_24_35_1' value=''    aria-required='true'    \/>\n                                        <label for='input_24_35_1' id='input_24_35_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_24_35_2_container' >\n                                        <input type='text' name='input_35.2' id='input_24_35_2' value=''     aria-required='false'   \/>\n                                        <label for='input_24_35_2' id='input_24_35_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_24_35_3_container' >\n                                    <input type='text' name='input_35.3' id='input_24_35_3' value=''    aria-required='true'    \/>\n                                    <label for='input_24_35_3' id='input_24_35_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_24_35_4_container' >\n                                        <input type='text' name='input_35.4' id='input_24_35_4' value=''      aria-required='true'    \/>\n                                        <label for='input_24_35_4' id='input_24_35_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_24_35_5_container' >\n                                    <input type='text' name='input_35.5' id='input_24_35_5' value=''    aria-required='true'    \/>\n                                    <label for='input_24_35_5' id='input_24_35_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_24_35_6_container' >\n                                        <select name='input_35.6' id='input_24_35_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_24_35_6' id='input_24_35_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_24_75\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Incident Location<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_75'>\n\t\t\t<div class='gchoice gchoice_24_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Annual Physical'  id='choice_24_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_0' id='label_24_75_0'>Annual Physical<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Detail'  id='choice_24_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_1' id='label_24_75_1'>Detail<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Headquarters'  id='choice_24_75_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_2' id='label_24_75_2'>Headquarters<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='HWC'  id='choice_24_75_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_3' id='label_24_75_3'>HWC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='On Scene EMS'  id='choice_24_75_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_4' id='label_24_75_4'>On Scene EMS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='On Scene Fire'  id='choice_24_75_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_5' id='label_24_75_5'>On Scene Fire<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Other'  id='choice_24_75_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_6' id='label_24_75_6'>Other<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Responding\/Returning'  id='choice_24_75_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_7' id='label_24_75_7'>Responding\/Returning<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Shops'  id='choice_24_75_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_8' id='label_24_75_8'>Shops<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Special Operations'  id='choice_24_75_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_9' id='label_24_75_9'>Special Operations<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Station'  id='choice_24_75_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_10' id='label_24_75_10'>Station<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_75_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Training Facility'  id='choice_24_75_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_75_11' id='label_24_75_11'>Training Facility<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_24_82\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Incident Location of Fire<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_82'>\n\t\t\t<div class='gchoice gchoice_24_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Commercial'  id='choice_24_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_0' id='label_24_82_0'>Commercial<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='High Rise'  id='choice_24_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_1' id='label_24_82_1'>High Rise<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Mobile Home'  id='choice_24_82_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_2' id='label_24_82_2'>Mobile Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Nursing Home'  id='choice_24_82_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_3' id='label_24_82_3'>Nursing Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Other'  id='choice_24_82_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_4' id='label_24_82_4'>Other<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Residential-Double'  id='choice_24_82_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_5' id='label_24_82_5'>Residential-Double<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Residential-Multi-Unit'  id='choice_24_82_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_6' id='label_24_82_6'>Residential-Multi-Unit<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Residential-Single'  id='choice_24_82_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_7' id='label_24_82_7'>Residential-Single<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='School'  id='choice_24_82_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_8' id='label_24_82_8'>School<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Vacant-Commercial'  id='choice_24_82_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_9' id='label_24_82_9'>Vacant-Commercial<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_82_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Vacant-Residential'  id='choice_24_82_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_82_10' id='label_24_82_10'>Vacant-Residential<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_36\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_36' >Day of the Week<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_24_36' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Monday' >Monday<\/option><option value='Tuesday' >Tuesday<\/option><option value='Wednesday' >Wednesday<\/option><option value='Thursday' >Thursday<\/option><option value='Friday' >Friday<\/option><option value='Saturday' >Saturday<\/option><option value='Sunday' >Sunday<\/option><\/select><\/div><\/div><div id=\"field_24_37\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_37' >Approx. Time of Day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_24_37' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='00:01-04:00 hrs' >00:01-04:00 hrs<\/option><option value='04:01-08:00 hrs' >04:01-08:00 hrs<\/option><option value='08:01-12:00 hrs' >08:01-12:00 hrs<\/option><option value='12:01-16:00 hrs' >12:01-16:00 hrs<\/option><option value='16:01-20:00 hrs' >16:01-20:00 hrs<\/option><option value='20:01-24:00 hrs' >20:01-24:00 hrs<\/option><\/select><\/div><\/div><div id=\"field_24_38\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_38' >Age Range<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_24_38' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='21-30' >21-30<\/option><option value='31-40' >31-40<\/option><option value='41-50' >41-50<\/option><option value='51-60' >51-60<\/option><option value='61-70' >61-70<\/option><\/select><\/div><\/div><div id=\"field_24_72\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_72' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_24_72' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_40\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Injury Information<\/h3><\/div><fieldset id=\"field_24_76\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_newline gf_list_2col o_medium\"  data-field-class=\"gf_newline gf_list_2col o_medium\"><legend class='gfield_label'  >Type of Injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_76'>\n\t\t\t<div class='gchoice gchoice_24_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Abrasion'  id='choice_24_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_0' id='label_24_76_0'>Abrasion<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Burn'  id='choice_24_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_1' id='label_24_76_1'>Burn<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Cancer'  id='choice_24_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_2' id='label_24_76_2'>Cancer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Cardiac Symptoms'  id='choice_24_76_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_3' id='label_24_76_3'>Cardiac Symptoms<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Contusion\/bruising'  id='choice_24_76_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_4' id='label_24_76_4'>Contusion\/bruising<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Cut\/Laceration'  id='choice_24_76_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_5' id='label_24_76_5'>Cut\/Laceration<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Crushed'  id='choice_24_76_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_6' id='label_24_76_6'>Crushed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Dehydration'  id='choice_24_76_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_7' id='label_24_76_7'>Dehydration<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Difficulty breathing'  id='choice_24_76_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_8' id='label_24_76_8'>Difficulty breathing<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Eye injury'  id='choice_24_76_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_9' id='label_24_76_9'>Eye injury<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Fracture'  id='choice_24_76_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_10' id='label_24_76_10'>Fracture<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Frostbite\/cold exposure'  id='choice_24_76_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_11' id='label_24_76_11'>Frostbite\/cold exposure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Heat related\/exhaustion'  id='choice_24_76_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_12' id='label_24_76_12'>Heat related\/exhaustion<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Infectious exposure'  id='choice_24_76_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_13' id='label_24_76_13'>Infectious exposure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Nausea'  id='choice_24_76_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_14' id='label_24_76_14'>Nausea<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Strain\/sprain'  id='choice_24_76_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_15' id='label_24_76_15'>Strain\/sprain<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Neurological'  id='choice_24_76_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_16' id='label_24_76_16'>Neurological<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_76_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Other (fill in the blank)'  id='choice_24_76_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_76_17' id='label_24_76_17'>Other (fill in the blank)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_42\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_newline o_medium\"  data-field-class=\"gf_newline o_medium\"><label class='gfield_label' for='input_24_42' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_24_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_24_80\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_newline gf_list_2col o_medium\"  data-field-class=\"gf_newline gf_list_2col o_medium\"><legend class='gfield_label'  >Body Part Injured<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_80'>\n\t\t\t<div class='gchoice gchoice_24_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Abdomen'  id='choice_24_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_0' id='label_24_80_0'>Abdomen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Arm'  id='choice_24_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_1' id='label_24_80_1'>Arm<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Chest\/Ribs'  id='choice_24_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_2' id='label_24_80_2'>Chest\/Ribs<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Elbow'  id='choice_24_80_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_3' id='label_24_80_3'>Elbow<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Finger'  id='choice_24_80_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_4' id='label_24_80_4'>Finger<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Groin'  id='choice_24_80_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_5' id='label_24_80_5'>Groin<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Hand'  id='choice_24_80_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_6' id='label_24_80_6'>Hand<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Heart'  id='choice_24_80_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_7' id='label_24_80_7'>Heart<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Knee'  id='choice_24_80_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_8' id='label_24_80_8'>Knee<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Lungs'  id='choice_24_80_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_9' id='label_24_80_9'>Lungs<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Neck'  id='choice_24_80_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_10' id='label_24_80_10'>Neck<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Wrist'  id='choice_24_80_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_11' id='label_24_80_11'>Wrist<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Ankle'  id='choice_24_80_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_12' id='label_24_80_12'>Ankle<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Back'  id='choice_24_80_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_13' id='label_24_80_13'>Back<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Ear'  id='choice_24_80_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_14' id='label_24_80_14'>Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Eye'  id='choice_24_80_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_15' id='label_24_80_15'>Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Foot'  id='choice_24_80_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_16' id='label_24_80_16'>Foot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Hamstring'  id='choice_24_80_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_17' id='label_24_80_17'>Hamstring<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_18'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Head'  id='choice_24_80_18' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_18' id='label_24_80_18'>Head<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_19'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Hip'  id='choice_24_80_19' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_19' id='label_24_80_19'>Hip<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_20'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Leg'  id='choice_24_80_20' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_20' id='label_24_80_20'>Leg<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_21'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Mouth'  id='choice_24_80_21' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_21' id='label_24_80_21'>Mouth<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_22'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Shoulder'  id='choice_24_80_22' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_22' id='label_24_80_22'>Shoulder<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_23'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Toe'  id='choice_24_80_23' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_23' id='label_24_80_23'>Toe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_80_24'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Other (fill-in)'  id='choice_24_80_24' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_80_24' id='label_24_80_24'>Other (fill-in)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_44\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_newline o_medium\"  data-field-class=\"gf_newline o_medium\"><label class='gfield_label' for='input_24_44' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_24_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_24_83\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Injury Side (if applicable)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_83'>\n\t\t\t<div class='gchoice gchoice_24_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Right side'  id='choice_24_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_83_0' id='label_24_83_0'>Right side<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Left side'  id='choice_24_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_83_1' id='label_24_83_1'>Left side<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_83_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Both sides'  id='choice_24_83_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_83_2' id='label_24_83_2'>Both sides<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_83_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='N\/A'  id='choice_24_83_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_83_3' id='label_24_83_3'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_46\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_46' >Do you have an additional injury to report on from this same incident?<\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_24_46' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><fieldset id=\"field_24_81\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\"><legend class='gfield_label'  >Second Injury<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_81'>\n\t\t\t<div class='gchoice gchoice_24_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Abrasion'  id='choice_24_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_0' id='label_24_81_0'>Abrasion<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Burn'  id='choice_24_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_1' id='label_24_81_1'>Burn<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Cardiac Symptoms'  id='choice_24_81_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_2' id='label_24_81_2'>Cardiac Symptoms<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Chemical Exposure'  id='choice_24_81_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_3' id='label_24_81_3'>Chemical Exposure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Contusion\/bruising'  id='choice_24_81_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_4' id='label_24_81_4'>Contusion\/bruising<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Cut\/laceration'  id='choice_24_81_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_5' id='label_24_81_5'>Cut\/laceration<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Dehydration'  id='choice_24_81_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_6' id='label_24_81_6'>Dehydration<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Difficulty breathing'  id='choice_24_81_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_7' id='label_24_81_7'>Difficulty breathing<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Electric shock'  id='choice_24_81_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_8' id='label_24_81_8'>Electric shock<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Eye injury'  id='choice_24_81_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_9' id='label_24_81_9'>Eye injury<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Fracture'  id='choice_24_81_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_10' id='label_24_81_10'>Fracture<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Frostbite\/cold exposure'  id='choice_24_81_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_11' id='label_24_81_11'>Frostbite\/cold exposure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Heat related\/exhaustion'  id='choice_24_81_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_12' id='label_24_81_12'>Heat related\/exhaustion<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Infectious exposure'  id='choice_24_81_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_13' id='label_24_81_13'>Infectious exposure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Nausea'  id='choice_24_81_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_14' id='label_24_81_14'>Nausea<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Inhalation\/smoke'  id='choice_24_81_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_15' id='label_24_81_15'>Inhalation\/smoke<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Strain\/sprain'  id='choice_24_81_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_16' id='label_24_81_16'>Strain\/sprain<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_81_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Other (fill in the blank)'  id='choice_24_81_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_81_17' id='label_24_81_17'>Other (fill in the blank)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_52\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\"><label class='gfield_label' for='input_24_52' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_24_52' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_24_77\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_list_2col o_medium\"  data-field-class=\"gf_list_2col o_medium\"><legend class='gfield_label'  >Second Area Injured<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_77'>\n\t\t\t<div class='gchoice gchoice_24_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Abdomen'  id='choice_24_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_0' id='label_24_77_0'>Abdomen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Arm'  id='choice_24_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_1' id='label_24_77_1'>Arm<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Chest\/Ribs'  id='choice_24_77_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_2' id='label_24_77_2'>Chest\/Ribs<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Elbow'  id='choice_24_77_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_3' id='label_24_77_3'>Elbow<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Finger'  id='choice_24_77_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_4' id='label_24_77_4'>Finger<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Groin'  id='choice_24_77_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_5' id='label_24_77_5'>Groin<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Hand'  id='choice_24_77_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_6' id='label_24_77_6'>Hand<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Heart'  id='choice_24_77_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_7' id='label_24_77_7'>Heart<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Knee'  id='choice_24_77_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_8' id='label_24_77_8'>Knee<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Lungs'  id='choice_24_77_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_9' id='label_24_77_9'>Lungs<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Neck'  id='choice_24_77_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_10' id='label_24_77_10'>Neck<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Wrist'  id='choice_24_77_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_11' id='label_24_77_11'>Wrist<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Ankle'  id='choice_24_77_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_12' id='label_24_77_12'>Ankle<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Back'  id='choice_24_77_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_13' id='label_24_77_13'>Back<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Ear'  id='choice_24_77_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_14' id='label_24_77_14'>Ear<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Eye'  id='choice_24_77_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_15' id='label_24_77_15'>Eye<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Foot'  id='choice_24_77_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_16' id='label_24_77_16'>Foot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Hamstring'  id='choice_24_77_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_17' id='label_24_77_17'>Hamstring<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_18'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Head'  id='choice_24_77_18' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_18' id='label_24_77_18'>Head<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_19'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Hip'  id='choice_24_77_19' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_19' id='label_24_77_19'>Hip<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_20'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Leg'  id='choice_24_77_20' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_20' id='label_24_77_20'>Leg<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_21'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Mouth'  id='choice_24_77_21' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_21' id='label_24_77_21'>Mouth<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_22'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Shoulder'  id='choice_24_77_22' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_22' id='label_24_77_22'>Shoulder<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_77_23'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Other (fill-in)'  id='choice_24_77_23' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_77_23' id='label_24_77_23'>Other (fill-in)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_50\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gf_newline o_medium\"  data-field-class=\"gf_newline o_medium\"><label class='gfield_label' for='input_24_50' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_24_50' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_24_78\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Second Injury Side<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_78'>\n\t\t\t<div class='gchoice gchoice_24_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Right side'  id='choice_24_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_78_0' id='label_24_78_0'>Right side<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Left side'  id='choice_24_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_78_1' id='label_24_78_1'>Left side<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_78_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Both sides'  id='choice_24_78_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_78_2' id='label_24_78_2'>Both sides<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_78_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='N\/A'  id='choice_24_78_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_78_3' id='label_24_78_3'>N\/A<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_24_84\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible o_medium\"  data-field-class=\"o_medium\"><legend class='gfield_label'  >Cause of Injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_84'>\n\t\t\t<div class='gchoice gchoice_24_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Absorbed\/Inhaled\/Ingested'  id='choice_24_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_0' id='label_24_84_0'>Absorbed\/Inhaled\/Ingested<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Backdraft\/Flashover'  id='choice_24_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_1' id='label_24_84_1'>Backdraft\/Flashover<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Burn or Scald'  id='choice_24_84_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_2' id='label_24_84_2'>Burn or Scald<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Contact with Object'  id='choice_24_84_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_3' id='label_24_84_3'>Contact with Object<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Dive'  id='choice_24_84_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_4' id='label_24_84_4'>Dive<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Electric Shock'  id='choice_24_84_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_5' id='label_24_84_5'>Electric Shock<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Exposure'  id='choice_24_84_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_6' id='label_24_84_6'>Exposure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Lifting'  id='choice_24_84_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_7' id='label_24_84_7'>Lifting<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Occupational Disease'  id='choice_24_84_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_8' id='label_24_84_8'>Occupational Disease<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Overexertion\/Strain'  id='choice_24_84_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_9' id='label_24_84_9'>Overexertion\/Strain<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Other'  id='choice_24_84_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_10' id='label_24_84_10'>Other<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Structural Collapse'  id='choice_24_84_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_11' id='label_24_84_11'>Structural Collapse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Vehicle Accident'  id='choice_24_84_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_12' id='label_24_84_12'>Vehicle Accident<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_84_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Weather'  id='choice_24_84_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_84_13' id='label_24_84_13'>Weather<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_24_79\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_list_2col o_medium\"  data-field-class=\"gf_list_2col o_medium\"><legend class='gfield_label'  >Activity at Time of Injury (Please explain in detail in the narrative box)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_79'>\n\t\t\t<div class='gchoice gchoice_24_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='EMS'  id='choice_24_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_0' id='label_24_79_0'>EMS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Exercise'  id='choice_24_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_1' id='label_24_79_1'>Exercise<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Fire Ground'  id='choice_24_79_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_2' id='label_24_79_2'>Fire Ground<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Forcible Entry'  id='choice_24_79_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_3' id='label_24_79_3'>Forcible Entry<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Operate Apparatus'  id='choice_24_79_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_4' id='label_24_79_4'>Operate Apparatus<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Other'  id='choice_24_79_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_5' id='label_24_79_5'>Other<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='PFE'  id='choice_24_79_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_6' id='label_24_79_6'>PFE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Responding'  id='choice_24_79_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_7' id='label_24_79_7'>Responding<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Returning'  id='choice_24_79_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_8' id='label_24_79_8'>Returning<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Special Operations'  id='choice_24_79_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_9' id='label_24_79_9'>Special Operations<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Station Activities'  id='choice_24_79_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_10' id='label_24_79_10'>Station Activities<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Stepping Apparatus'  id='choice_24_79_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_11' id='label_24_79_11'>Stepping Apparatus<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Training'  id='choice_24_79_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_12' id='label_24_79_12'>Training<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_79_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='WPE'  id='choice_24_79_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_79_13' id='label_24_79_13'>WPE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_24_86\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Exercise Location<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_86'>\n\t\t\t<div class='gchoice gchoice_24_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='General Fitness - At Station'  id='choice_24_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_86_0' id='label_24_86_0'>General Fitness - At Station<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Work Conditioning\/Rehab'  id='choice_24_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_86_1' id='label_24_86_1'>Work Conditioning\/Rehab<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_86_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Recruit Workout'  id='choice_24_86_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_86_2' id='label_24_86_2'>Recruit Workout<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_59\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\"><label class='gfield_label' for='input_24_59' >Sharps Injury?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_24_59' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_24_60\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\"><label class='gfield_label' for='input_24_60' >Bodily Fluid Exposure Injury?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_24_60' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_24_67\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Employee Narrative<\/h3><\/div><div id=\"field_24_68\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_68' >Description of the Incident (Describe in detail how you were injured\/mechanism of injury)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_24_68' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_24_98\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >I would like a call from ProTeam Tactical Performance to discuss my injury.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_24_98'><div class='gchoice gchoice_24_98_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.1' type='checkbox'  value='Yes'  id='choice_24_98_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_98_1' id='label_24_98_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_98_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.2' type='checkbox'  value='No'  id='choice_24_98_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_98_2' id='label_24_98_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_89\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Note: If filling out the form on a cellphone, please close your browser once it has been submitted.<\/h3><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_24' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_24\"]){return false;}  window[\"gf_submitting_24\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_24\"]){return false;} window[\"gf_submitting_24\"]=true;  jQuery(\"#gform_24\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_24' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='24' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_24' value='WyJbXSIsIjkyY2UxZjcyNzc1MzE0YjJkMmYyM2Y2MTI2MWRlMzViIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_24' id='gform_target_page_number_24' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_24' id='gform_source_page_number_24' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_24' value='' \/>\n        <\/div>\n                        <\/form>\n                        <\/div><div class=\"pvc_clear\"><\/div><p id=\"pvc_stats_44441\" class=\"pvc_stats all  \" data-element-id=\"44441\" style=\"\"><i class=\"pvc-stats-icon medium\" aria-hidden=\"true\"><svg aria-hidden=\"true\" focusable=\"false\" data-prefix=\"far\" data-icon=\"chart-bar\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\" class=\"svg-inline--fa fa-chart-bar fa-w-16 fa-2x\"><path fill=\"currentColor\" d=\"M396.8 352h22.4c6.4 0 12.8-6.4 12.8-12.8V108.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v230.4c0 6.4 6.4 12.8 12.8 12.8zm-192 0h22.4c6.4 0 12.8-6.4 12.8-12.8V140.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v198.4c0 6.4 6.4 12.8 12.8 12.8zm96 0h22.4c6.4 0 12.8-6.4 12.8-12.8V204.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v134.4c0 6.4 6.4 12.8 12.8 12.8zM496 400H48V80c0-8.84-7.16-16-16-16H16C7.16 64 0 71.16 0 80v336c0 17.67 14.33 32 32 32h464c8.84 0 16-7.16 16-16v-16c0-8.84-7.16-16-16-16zm-387.2-48h22.4c6.4 0 12.8-6.4 12.8-12.8v-70.4c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v70.4c0 6.4 6.4 12.8 12.8 12.8z\" class=\"\"><\/path><\/svg><\/i> <img loading=\"lazy\" decoding=\"async\" width=\"16\" height=\"16\" alt=\"Loading\" src=\"https:\/\/ifdresourc.es\/forms\/wp-content\/plugins\/page-views-count\/ajax-loader-2x.gif\" border=0 \/><\/p><div class=\"pvc_clear\"><\/div>","protected":false},"excerpt":{"rendered":"<div class=\"pvc_clear\"><\/div>\n<p id=\"pvc_stats_44441\" class=\"pvc_stats all  \" data-element-id=\"44441\" style=\"\"><i class=\"pvc-stats-icon medium\" aria-hidden=\"true\"><svg aria-hidden=\"true\" focusable=\"false\" data-prefix=\"far\" data-icon=\"chart-bar\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\" class=\"svg-inline--fa fa-chart-bar fa-w-16 fa-2x\"><path fill=\"currentColor\" d=\"M396.8 352h22.4c6.4 0 12.8-6.4 12.8-12.8V108.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v230.4c0 6.4 6.4 12.8 12.8 12.8zm-192 0h22.4c6.4 0 12.8-6.4 12.8-12.8V140.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v198.4c0 6.4 6.4 12.8 12.8 12.8zm96 0h22.4c6.4 0 12.8-6.4 12.8-12.8V204.8c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v134.4c0 6.4 6.4 12.8 12.8 12.8zM496 400H48V80c0-8.84-7.16-16-16-16H16C7.16 64 0 71.16 0 80v336c0 17.67 14.33 32 32 32h464c8.84 0 16-7.16 16-16v-16c0-8.84-7.16-16-16-16zm-387.2-48h22.4c6.4 0 12.8-6.4 12.8-12.8v-70.4c0-6.4-6.4-12.8-12.8-12.8h-22.4c-6.4 0-12.8 6.4-12.8 12.8v70.4c0 6.4 6.4 12.8 12.8 12.8z\" class=\"\"><\/path><\/svg><\/i> <img loading=\"lazy\" decoding=\"async\" width=\"16\" height=\"16\" alt=\"Loading\" src=\"https:\/\/ifdresourc.es\/forms\/wp-content\/plugins\/page-views-count\/ajax-loader-2x.gif\" border=0 \/><\/p>\n<div class=\"pvc_clear\"><\/div>\n","protected":false},"author":78,"featured_media":0,"parent":44437,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"generate_page_header":"","footnotes":""},"class_list":["post-44441","page","type-page","status-publish"],"acf":[],"a3_pvc":{"activated":true,"total_views":0,"today_views":0},"featured_image_src":null,"featured_image_src_square":null,"_links":{"self":[{"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/pages\/44441","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/users\/78"}],"replies":[{"embeddable":true,"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/comments?post=44441"}],"version-history":[{"count":1,"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/pages\/44441\/revisions"}],"predecessor-version":[{"id":44442,"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/pages\/44441\/revisions\/44442"}],"up":[{"embeddable":true,"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/pages\/44437"}],"wp:attachment":[{"href":"https:\/\/ifdresourc.es\/forms\/wp-json\/wp\/v2\/media?parent=44441"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}