var qsProxy = {};
function FrameBuilder(formId,appendTo,initialHeight,iframeCode,title,embedStyleJSON){this.formId=formId;this.initialHeight=initialHeight;this.iframeCode=iframeCode;this.frame=null;this.timeInterval=200;this.appendTo=appendTo||false;this.formSubmitted=0;this.frameMinWidth='100%';this.defaultHeight='';this.createFrame=function(){this.iframeDomId=document.getElementById(this.formId)?this.formId+'_'+new Date().getTime():this.formId;if(typeof $jot!=='undefined'){var iframe=document.getElementById("221086844553055");var parent=$jot(iframe).closest('.jt-feedback.u-responsive-lightbox');if(parent){this.iframeDomId='lightbox-'+this.iframeDomId;}}
var iframe=document.createElement('iframe');var titleEscaped=title.replace(/[\\"']/g,'\\$&').replace(/&amp;/g,'&');var queryParameters=new URLSearchParams(window.location.search);queryParameters.set('parentURL',encodeURIComponent(window.location.href));queryParameters.set('jsForm',true);Object.entries(FrameBuilder.get).forEach(([key,value])=>{if(typeof value==='object'){Object.entries(value).forEach(([valueKey,valueVal])=>{queryParameters.set(`${key}[${valueKey}]`,valueVal);})}else{queryParameters.set(key,value);}});var queryParametersString=queryParameters.toString();iframe.title=titleEscaped;iframe.src=`https://form.jotform.com/221086844553055${queryParametersString?`?${queryParametersString}`:''}`;iframe.allowtransparency=true;iframe.allow='geolocation; microphone; camera';iframe.allowfullscreen=true;iframe.name=this.formId;iframe.id=this.iframeDomId;iframe.style.width='10px';iframe.style.minWidth=this.frameMinWidth;iframe.style.display='block';iframe.style.overflow='hidden';iframe.style.height=this.initialHeight+'px';iframe.style.border='none';iframe.scrolling='no';if(this.appendTo===false){var jsformScript=document.querySelector('script[src*="jsform/'+this.formId+'"]:not([data-iframe-appended])');var scriptLocatedInHead=!!jsformScript.closest('head');if(scriptLocatedInHead){var isBodyExists=!!document.body;if(isBodyExists){document.body.appendChild(iframe);}else{document.addEventListener('DOMContentLoaded',function(){if(document.body){document.body.appendChild(iframe);}else{console.log('No body element found to append the iframe');}});}}else{jsformScript.parentNode.insertBefore(iframe,jsformScript.nextSibling);}
jsformScript.dataset.iframeAppended=true;}else{document.getElementById(this.appendTo).appendChild(iframe);}};this.createFrame();}
FrameBuilder.get=qsProxy||[];var initialHeight="LEGACY"==='CARD'?640:539;var i221086844553055=new FrameBuilder("221086844553055",false,initialHeight,"<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html lang=\"en-US\"  class=\"supernova \"><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=https%3A%2F%2Fform.jotform.com%2F221086844553055\" title=\"oEmbed Form\">\n<link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=https%3A%2F%2Fform.jotform.com%2F221086844553055\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"Assignment Despite Objection\" >\n<meta property=\"og:url\" content=\"https:\/\/form.jotform.com\/221086844553055\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\" >\n<meta name=\"slack-app-id\" content=\"AHNMASS8M\">\n<meta property=\"og:image\" content=\"https:\/\/cdn.jotfor.ms\/assets\/img\/landing\/opengraph.png\" \/>\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/assets\/img\/favicons\/favicon-2021-light%402x.png\">\n<link rel=\"apple-touch-icon\" href=\"https:\/\/cdn.jotfor.ms\/assets\/img\/favicons\/favicon-2021-light%402x.png\">\n<script>\n          var favicon = document.querySelector('link[rel=\"shortcut icon\"]');\n          window.isDarkMode = (window.matchMedia && window.matchMedia('(prefers-color-scheme: dark)').matches);\n          if(favicon && window.isDarkMode) {\n              favicon.href = favicon.href.replaceAll('favicon-2021-light%402x.png', 'favicon-2021-dark%402x.png');\n          }\n      <\/script><link rel=\"canonical\" href=\"https:\/\/form.jotform.com\/221086844553055\" \/>\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Assignment Despite Objection<\/title>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn01.jotfor.ms\/stylebuilder\/static\/form-common.css?v=18cfc0e\n\"\/>\n<style type=\"text\/css\">@media print{*{-webkit-print-color-adjust: exact !important;color-adjust: exact !important;}.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}}<\/style>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn02.jotfor.ms\/themes\/CSS\/5e6b428acc8c4e222d1beb91.css?v=3.3.51801&themeRevisionID=5f7ed99c2c2c7240ba580251\"\/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn03.jotfor.ms\/css\/styles\/payment\/payment_styles.css?3.3.51801\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn01.jotfor.ms\/css\/styles\/payment\/payment_feature.css?3.3.51801\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn02.jotfor.ms\/stylebuilder\/static\/donationBox.css?v=3.3.51801\">\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n*,\n*:after,\n*:before {\n  box-sizing: border-box;\n}\n.form-all {\n  font-family: \"Inter\", sans-serif;\n}\n.main .jotform-form {\n  width: 100%;\n  padding: 0 3%;\n}\n.form-all {\n  display: flex;\n  flex-direction: column;\n  width: 100%;\n  max-width: 752px;\n}\n.form-line-active {\n  background-color: #f1f5ff;\n}\n.form-all {\n  font-size: 16px;\n}\nli.form-line {\n  margin-top: 12px;\n  margin-bottom: 12px;\n}\n.form-line {\n  padding: 12px 10px;\n}\n.form-section {\n  padding: 0px 38px;\n}\n.form-textbox,\n.form-textarea,\nli[data-type=control_fileupload] .qq-upload-button,\n.signature-wrapper {\n  border-color: #b8bdc9;\n}\n.form-textarea:hover,\n.form-textbox:hover,\nli[data-type=control_fileupload] .qq-upload-button:hover,\n.signature-wrapper:hover {\n  border-color: rgba(184, 189, 201, 0.5);\n  box-shadow: 0 0 0 2px rgba(184, 189, 201, 0.25);\n}\n.form-textarea:focus,\n.form-textbox:focus,\nli[data-type=control_fileupload] .qq-upload-button:focus,\n.signature-wrapper:focus {\n  border-color: #b8bdc9;\n  box-shadow: 0 0 0 3px rgba(184, 189, 201, 0.25);\n}\n.form-textbox,\n.form-textarea,\n.form-radio-other-input,\n.form-checkbox-other-input,\n.form-captcha input,\n.form-spinner input {\n  background-color: #ffffff;\n}\n.form-label {\n  font-family: \"Inter\", sans-serif;\n}\n.form-line-column {\n  width: calc(50% - 8px);\n}\n.form-dropdown:first-child {\n  border-color: #b8bdc9;\n  color: #8894ab;\n  background-color: #ffffff;\n}\n.form-checkbox-item label,\n.form-checkbox-item span,\n.form-radio-item label,\n.form-radio-item span {\n  color: #404a64;\n}\n.form-radio-item,\n.form-checkbox-item {\n  padding-bottom: 0px !important;\n}\n.form-radio-item:last-child,\n.form-checkbox-item:last-child {\n  padding-bottom: 0;\n}\n.form-single-column .form-checkbox-item,\n.form-single-column .form-radio-item {\n  width: 100%;\n}\n.form-checkbox-item .editor-container div,\n.form-radio-item .editor-container div {\n  position: relative;\n}\n.form-checkbox-item .editor-container div:before,\n.form-radio-item .editor-container div:before {\n  display: inline-block;\n  vertical-align: middle;\n  left: 0;\n  width: 20px;\n  height: 20px;\n}\n.form-checkbox-item input,\n.form-radio-item input {\n  margin-top: 2px;\n}\n.form-checkbox:checked + label:before,\n.form-checkbox:checked + span:before {\n  background-color: #b8bdc9;\n  border-color: #b8bdc9;\n}\n.form-radio:checked + label:before,\n.form-radio:checked + span:before {\n  border-color: #b8bdc9;\n}\n.form-radio:checked + label:after,\n.form-radio:checked + span:after {\n  background-color: #b8bdc9;\n}\n.form-checkbox:hover + label:before,\n.form-checkbox:hover + span:before,\n.form-radio:hover + label:before,\n.form-radio:hover + span:before {\n  border-color: rgba(184, 189, 201, 0.5);\n  box-shadow: 0 0 0 2px rgba(184, 189, 201, 0.25);\n}\n.form-checkbox:focus + label:before,\n.form-checkbox:focus + span:before,\n.form-radio:focus + label:before,\n.form-radio:focus + span:before {\n  border-color: #b8bdc9;\n  box-shadow: 0 0 0 3px rgba(184, 189, 201, 0.25);\n}\n.submit-button {\n  font-size: 16px;\n  font-weight: normal;\n  font-family: \"Inter\", sans-serif;\n  border-color: #b8bdc9;\n}\n.submit-button {\n  min-width: 180px;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  font-family: \"Inter\", sans-serif;\n  font-size: 16px;\n  font-weight: normal;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  min-width: 128px;\n}\nli[data-type=\"control_image\"] div {\n  text-align: left;\n}\nli[data-type=\"control_image\"] img {\n  border: none;\n  border-width: 0px !important;\n  border-style: solid !important;\n  border-color: false !important;\n}\n.supernova {\n  height: 100%;\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n.supernova {\n  background-image: none;\n}\n#stage {\n  background-image: none;\n}\n\/* | *\/\n.form-all {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n.form-header-group {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n}\n.header-large h1.form-header {\n  font-size: 2em;\n}\n.header-large h2.form-header {\n  font-size: 1.5em;\n}\n.header-large h3.form-header {\n  font-size: 1.17em;\n}\n.header-large h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-large h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-large h3 + .form-subHeader {\n  font-size: .75em;\n}\n.header-default h1.form-header {\n  font-size: 2em;\n}\n.header-default h2.form-header {\n  font-size: 1.5em;\n}\n.header-default h3.form-header {\n  font-size: 1.17em;\n}\n.header-default h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-default h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-default h3 + .form-subHeader {\n  font-size: .75em;\n}\n.header-small h1.form-header {\n  font-size: 2em;\n}\n.header-small h2.form-header {\n  font-size: 1.5em;\n}\n.header-small h3.form-header {\n  font-size: 1.17em;\n}\n.header-small h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-small h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-small h3 + .form-subHeader {\n  font-size: .75em;\n}\n.form-header-group {\n  text-align: left;\n}\n.form-header-group {\n  font-family: \"Inter\", sans-serif;\n}\ndiv.form-header-group.header-large {\n  margin: 0px -38px;\n}\ndiv.form-header-group.header-large {\n  padding: 40px 52px;\n}\n.form-header-group .form-header,\n.form-header-group .form-subHeader {\n  color: #2c3345;\n}\n.form-collapse-table {\n  border: 1px solid rgba(0, 0, 0, 0.2);\n  background-color: #e5e7f2;\n  box-shadow: 0 1px 0 rgba(255,255,255,0.5) inset, 0 1px 0 rgba(0,0,0,0.2);\n  color: #2c3345;\n}\n.form-collapse-table .form-collapse-mid {\n  text-shadow: none;\n}\n.form-line-error {\n  overflow: hidden;\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #ffd6d6;\n}\n.form-line-error .form-error-message {\n  background-color: #f23a3c;\n  clear: both;\n  float: none;\n}\n.form-line-error .form-error-message .form-error-arrow {\n  border-bottom-color: #f23a3c;\n}\n.form-line-error input:not(#coupon-input),\n.form-line-error textarea,\n.form-line-error .form-validation-error {\n  border: 1px solid #f23a3c;\n  box-shadow: 0 0 3px #f23a3c;\n}\n.supernova {\n  background-color: #ffffff;\n  background-color: #f3f3fe;\n}\n.supernova body {\n  background-color: transparent;\n}\n.supernova .form-all,\n.form-all {\n  background-color: #ffffff;\n}\n.form-textbox,\n.form-textarea,\n.form-radio-other-input,\n.form-checkbox-other-input,\n.form-captcha input,\n.form-spinner input {\n  background-color: #ffffff;\n}\n.form-matrix-table tr {\n  border-color: #e6e6e6;\n}\n.form-matrix-table tr:nth-child(2n) {\n  background-color: #f2f2f2;\n}\n.form-all {\n  color: #2c3345;\n}\n.form-label-top,\n.form-label-left,\n.form-label-right,\n.form-html {\n  color: #2c3345;\n}\n.form-line-error {\n  overflow: hidden;\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #ffd6d6;\n}\n\n\/*PREFERENCES STYLE*\/\n  \/* NEW THEME STYLE *\/\n\n  \/* colors *\/\n\n  .form-textbox, .form-textarea {\n    color: #2c3345;\n  }\n  .rating-item input:hover+label {\n    color: #b8bdc9;\n  }\n  li[data-type=control_fileupload] .qq-upload-button,\n  .until-text,\n  .form-submit-reset {\n    color: #b8bdc9;\n  }\n\n  .stageEmpty.isSmall{\n    color: #b8bdc9;\n  }\n\n  .rating-item label {\n    color: #b8bdc9;\n  }\n  .currentDate,\n  .pickerItem select,\n  .appointmentCalendar .calendarDay,\n  .calendar.popup th,\n  .calendar.popup table tbody td,\n  .calendar-new-header>*,\n  .form-collapse-table {\n    color: #2C3345;\n  }\n  .appointmentCalendar .dayOfWeek {\n    color: #2C3345;\n  }\n  .appointmentSlotsContainer > * {\n    color: #b8bdc9;\n  }\n  li[data-type=control_fileupload] .jfUpload-heading,\n  ::placeholder,\n  .form-dropdown.is-active,\n  .form-dropdown:first-child,\n  .form-spinner-input {\n    color: #e5eaf4;\n  }\n  .appointmentCalendar .calendarWeek .calendarDay.isUnavailable,\n  .calendar tr.days td.otherDay,\n  .calendar tr.days td:hover:not(.unselectable) {\n    color: #e5eaf4;\n  }\n  span.form-sub-label, label.form-sub-label, div.form-header-group .form-subHeader,\n  .rating-item-title.for-to > label:first-child,\n  .rating-item-title.for-from > label:first-child,\n  .rating-item-title .editor-container * {\n    color: #57647E;\n  }\n  .form-pagebreak-back{\n    color: #FFFFFF;\n  }\n  .rating-item input:checked+label,\n  .rating-item input:focus+label {\n    color: #FFFFFF;\n  }\n  .clear-pad-btn {\n    color: #FFFFFF;\n  }\n  .form-textbox::placeholder,\n  .form-dropdown:not(.time-dropdown):not(:required),\n  .form-dropdown:not(:required),\n  .form-dropdown:required:invalid {\n    color: #e5eaf4;\n  }\n  \/* border-colors *\/\n  .form-dropdown,\n  .form-textarea,\n  .form-textbox,\n  li[data-type=control_fileupload] .qq-upload-button,\n  .rating-item label,\n  .rating-item input:focus+label,\n  .rating-item input:checked+label,\n  .jf-form-buttons,\n  .form-checkbox+label:before, .form-checkbox+span:before, .form-radio+label:before, .form-radio+span:before,\n  .signature-pad-passive,\n  .signature-wrapper,\n  .appointmentCalendarContainer,\n  .appointmentField .timezonePickerName,\n  .appointmentDayPickerButton,\n  .appointmentCalendarContainer .monthYearPicker .pickerItem+.pickerItem,\n  .appointmentCalendarContainer .monthYearPicker,\n  .appointmentCalendar .calendarDay.isActive .calendarDayEach, .appointmentCalendar .calendarDay.isToday .calendarDayEach, .appointmentCalendar .calendarDay:not(.empty):hover .calendarDayEach,\n  .calendar.popup:before,\n  .calendar-new-month,\n  .form-matrix-column-headers, .form-matrix-table td, .form-matrix-table td:last-child,\n  .form-matrix-table th, .form-matrix-table th:last-child, .form-matrix-table tr:last-child td, .form-matrix-table tr:last-child th, .form-matrix-table tr:not([role=group])+tr[role=group] th,\n  .form-matrix-headers.form-matrix-column-headers,\n  .isSelected .form-matrix-column-headers:nth-last-of-type(2),\n  li[data-type=control_inline] input[type=email], li[data-type=control_inline] input[type=number],\n  li[data-type=control_inline] input[type=tel], li[data-type=control_inline] input[type=text],\n  .stageEmpty.isSmall {\n    border-color: #b8bdc9;\n  }\n  .rating-item input:hover+label {\n    border-color: #b8bdc9;\n  }\n  .appointmentSlot,\n  .form-checkbox:checked+label:before, .form-checkbox:checked+span:before, .form-checkbox:checked+span label:before,\n  .form-radio:checked+label:before, .form-radio:checked+span:before,\n  .form-dropdown:focus, .form-textarea:focus, .form-textbox:focus, .signature-wrapper:focus,\n  .form-line[data-payment=\"true\"] .form-product-item .p_checkbox .checked,\n  .form-dropdown:hover, .form-textarea:hover, .form-textbox:hover, .signature-wrapper:hover {\n    border-color: #b8bdc9;\n  }\n\n  .calendar tr.days td:hover:not(.unselectable):after {\n    border-color: #e5eaf4;\n  }\n  .form-header-group,\n  .form-buttons-wrapper, .form-pagebreak, .form-submit-clear-wrapper,\n  .form-pagebreak-next,\n  .form-pagebreak-back,\n  .form-checkbox:hover+label:before, .form-checkbox:hover+span:before, .form-radio:hover+label:before, .form-radio:hover+span:before,\n  .divider {\n    border-color: #F3F3FE;\n  }\n  .form-pagebreak-back:focus, .form-pagebreak-next:focus, .form-submit-button:focus {\n    border-color: rgba(46, 105, 255, 1);\n  }\n  \/* background-colors *\/\n  .form-line-active {\n    background-color: #F1F5FF;\n  }\n  .form-line-error {\n    background-color: #FFD6D6;\n  }\n  .form-matrix-column-headers, .form-matrix-row-headers,\n  .form-spinner-button-container>*,\n  .form-collapse-table,\n  .form-collapse-table:hover,\n  .appointmentDayPickerButton {\n    background-color: #e5eaf4;\n  }\n  .calendar.popup, .calendar.popup table,\n  .calendar.popup table tbody td:after{\n    background-color: #FFFFFF;\n  }\n\n  .appointmentCalendar .calendarDay.isActive .calendarDayEach,\n  .appointmentFieldRow.forSelectedDate,\n  .calendar.popup tr.days td.selected:after,\n  .calendar.popup:after,\n  .submit-button,\n  .form-checkbox:checked+label:before, .form-checkbox:checked+span:before, .form-checkbox:checked+span label:before,\n  .form-radio+label:after, .form-radio+span:after,\n  .rating-item input:checked+label,\n  .appointmentCalendar .calendarDay:after,\n  .form-line[data-payment=\"true\"] .form-product-item .p_checkbox .checked,\n  .rating-item input:focus+label {\n    background-color: #2e69ff;\n  }\n  .appointmentSlot.active {\n    background-color: #2e69ff !important;\n  }\n  .clear-pad-btn,\n  .appointmentCalendar .dayOfWeek,\n  .calendar.popup th {\n    background-color: #F3F3FE !important;\n  }\n  .appointmentField .timezonePicker:hover+.timezonePickerName,\n  .form-spinner-button-container>*:hover {\n    background-color: #96B4FF;\n  }\n  .form-matrix-values,\n  .form-matrix-values,\n  .signature-wrapper,\n  .signature-pad-passive,\n  .rating-item label,\n  .form-checkbox+label:before, .form-checkbox+span:before,\n  .form-radio+label:before, .form-radio+span:before {\n    background-color: #FFFFFF;\n  }\n  li[data-type=control_fileupload] .qq-upload-button {\n    background-color: #FFFFFF;\n  }\n  .JotFormBuilder .appContainer #app li.form-line[data-type=control_matrix].isSelected\n  .questionLine-editButton.forRemove:after, \n  .JotFormBuilder .appContainer #app li.form-line[data-type=control_matrix].isSelected .questionLine-editButton.forRemove:before {\n    background-color: #FFFFFF;\n  }\n  .appointmentCalendarContainer, .appointmentSlot,\n  .rating-item-title.for-to > label:first-child,\n  .rating-item-title.for-from > label:first-child,\n  .rating-item-title .editor-container *,\n  .calendar-opened {\n    background-color: transparent;\n  }\n  .page-section li.form-line-active[data-type=\"control_button\"] {\n    background-color: #F1F5FF;\n  }\n  .appointmentCalendar .calendarDay.isSelected:after {\n    color: #FFFFFF;\n  }\n  \/* shadow *\/\n  .form-dropdown:hover, .form-textarea:hover, .form-textbox:hover, .signature-wrapper:hover,\n  .calendar.popup:before,\n  .jSignature:hover,\n  li[data-type=control_fileupload] .qq-upload-button-hover,\n  .form-line[data-payment=\"true\"] .form-product-item .p_checkbox .checked,\n  .form-line[data-payment=\"true\"] .form-product-item .p_checkbox:hover .select_border,\n  .form-checkbox:hover+label:before, .form-checkbox:hover+span:before, .form-radio:hover+label:before, .form-radio:hover+span:before,\n  .calendar.popup:before {\n    border-color: rgba(46, 105, 255, 0.5);\n    box-shadow: 0 0 0 2px rgba(46, 105, 255, 0.25);\n  }\n  .form-dropdown:focus, .form-textarea:focus, .form-textbox:focus, .signature-wrapper:focus,\n  li[data-type=control_fileupload] .qq-upload-button-focus,\n  .form-checkbox:focus+label:before, .form-checkbox:focus+span:before, .form-radio:focus+label:before, .form-radio:focus+span:before,\n  .calendar.popup:before {\n    border-color: rgba(46, 105, 255, 1);\n    box-shadow: 0 0 0 3px rgba(46, 105, 255, 0.25);\n  }\n  .calendar.popup table tbody td{\n    box-shadow: none;\n  }\n\n  \/* button colors *\/\n  .submit-button {\n    background-color: #18BD5B;\n    border-color: #18BD5B;\n  }\n  .submit-button:hover {\n    background-color: #16AA52;\n    border-color: #16AA52;\n  }\n  .form-pagebreak-next {\n    background-color: #F3F3FE;\n  }\n  .form-pagebreak-back {\n    background-color: #F3F3FE;\n  }\n  .form-pagebreak-back:hover {\n    background-color: #CED0DA;\n    border-color: #CED0DA;\n  }\n  .form-pagebreak-next:hover {\n    background-color: #2554CC;\n    border-color: #2554CC;\n  }\n  .form-sacl-button, .form-submit-print {\n    background-color: transparent;\n    color: #b8bdc9;\n    border-color: #b8bdc9;\n  }\n  .form-sacl-button:hover, .form-submit-print:hover,\n  .appointmentSlot:not(.disabled):not(.active):hover,\n  .appointmentDayPickerButton:hover,\n  .rating-item input:hover+label {\n    background-color: #96B4FF;\n  }\n\n  \/* payment styles *\/\n  \n  .form-line[data-payment=true] .form-textbox,\n  .form-line[data-payment=true] .select-area,\n  .form-line[data-payment=true] #coupon-input,\n  .form-line[data-payment=true] #coupon-container input,\n  .form-line[data-payment=true] input#productSearch-input,\n  .form-line[data-payment=true] .form-product-category-item:after,\n  .form-line[data-payment=true] .filter-container .dropdown-container .select-content,\n  .form-line[data-payment=true] .form-textbox.form-product-custom_quantity,\n  .form-line[data-payment=\"true\"] .form-product-item .p_checkbox .select_border,\n  .form-line[data-payment=\"true\"] .form-product-item .form-product-container .form-sub-label-container span.select_cont,\n  .form-line[data-payment=true] select.form-dropdown,\n  .form-line[data-payment=true] #payment-category-dropdown .select-area,\n  .form-line[data-payment=true] #payment-sorting-products-dropdown .select-area,\n  .form-line[data-payment=true] .dropdown-container .select-content {\n    border-color: #b8bdc9;\n    border-color: #C3CAD8;\n  }\n  .form-line[data-payment=\"true\"] hr,\n  .form-line[data-payment=true] .p_item_separator,\n  .form-line[data-payment=\"true\"] .payment_footer.new_ui,\n  .form-line.card-3col .form-product-item.new_ui,\n  .form-line.card-2col .form-product-item.new_ui {\n    border-color: #b8bdc9;\n    border-color: rgba(195,202,216,.5);\n  }\n  .form-line[data-payment=true] .form-product-category-item {\n    border-color: #b8bdc9;\n    border-color: #d9dde4;\n  }\n  .form-line[data-payment=true] #coupon-input,\n  .form-line[data-payment=true] .form-textbox.form-product-custom_quantity,\n  .form-line[data-payment=true] input#productSearch-input,\n  .form-line[data-payment=true] .select-area,\n  .form-line[data-payment=true] .custom_quantity,\n  .form-line[data-payment=true] .filter-container .select-content,\n  .form-line[data-payment=true] .p_checkbox .select_border,\n  .form-line[data-payment=true] #payment-category-dropdown .select-area,\n  .form-line[data-payment=true] #payment-sorting-products-dropdown .select-area,\n  .form-line[data-payment=true] .dropdown-container .select-content {\n    background-color: #FFFFFF;\n  }\n  .form-line[data-payment=true] .form-product-category-item.title_collapsed.has_selected_product .selected-items-icon {\n   background-color: #ffffff;\n   border-color: #ffffff;\n  }\n  .form-line[data-payment=true].form-line.card-3col .form-product-item,\n  .form-line[data-payment=true].form-line.card-2col .form-product-item {\n   background-color: undefined;\n  }\n  .form-line[data-payment=true] .payment-form-table input.form-textbox,\n  .form-line[data-payment=true] .payment-form-table input.form-dropdown,\n  .form-line[data-payment=true] .payment-form-table .form-sub-label-container > div,\n  .form-line[data-payment=true] .payment-form-table span.form-sub-label-container iframe,\n  .form-line[data-type=control_square] .payment-form-table span.form-sub-label-container iframe {\n    border-color: #b8bdc9;\n  }\n\n  \/* icons *\/\n  .appointmentField .timezonePickerName:before {\n    background-image: url(data:image\/svg+xml;base64,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);\n  }\n  .appointmentCalendarContainer .monthYearPicker .pickerArrow.prev:after {\n    background-image: url(data:image\/svg+xml;base64,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);\n  }\n  .appointmentCalendarContainer .monthYearPicker .pickerArrow.next:after {\n    background-image: url(data:image\/svg+xml;base64,PHN2ZyB3aWR0aD0iMTAiIGhlaWdodD0iNiIgdmlld0JveD0iMCAwIDEwIDYiIGZpbGw9Im5vbmUiIHhtbG5zPSJodHRwOi8vd3d3LnczLm9yZy8yMDAwL3N2ZyI+CjxwYXRoIGQ9Ik0xLjQwMjE4IDAuMjIzNDk3QzEuMDY2ODcgLTAuMDgwMTAyOCAwLjU2MDYwMiAtMC4wNzM1MDI4IDAuMjQzODY5IDAuMjQzMzk3Qy0wLjA4MTI4OTggMC41Njg2OTcgLTAuMDgxMjg5OCAxLjA5NjYgMC4yNDM4NjkgMS40MjE5QzAuMzkwOTU2IDEuNTU5OCAwLjM5MDk2NiAxLjU1OTggMC45MTA1MSAyLjA0NUMxLjU2MjU3IDIuNjU0IDEuNTYyNTYgMi42NTQgMi4zNDQ4OCAzLjM4NDZDMy45MTA0NCA0Ljg0NjcgMy45MTA0MyA0Ljg0NjcgNC40MzIyNyA1LjMzNDFDNC43NTg5NSA1LjYzMDcgNS4yNDkxNSA1LjYyOTcgNS41Njc2NCA1LjMzNDNMOS43Mzc0NiAxLjQ0MkMxMC4wODA1IDEuMTAwNyAxMC4wODcxIDAuNTcyMTk3IDkuNzU4NTMgMC4yNDMzOTdDOS40NDA0NCAtMC4wNzQ5MDI4IDguOTMwMjQgLTAuMDgwNTAyOCA4LjYwMjk3IDAuMjIzNTk3TDUuMDAxMDggMy41ODQ5TDEuNDAyMTggMC4yMjM0OTdaIiBmaWxsPSIjQ0ZDRkNGIi8+Cjwvc3ZnPgo=);\n  }\n  .appointmentField .timezonePickerName:after {\n    background-image: url(data:image\/svg+xml;base64,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);\n    width: 11px;\n  }\n  li[data-type=control_datetime] [data-wrapper-react=true].extended>div+.form-sub-label-container .form-textbox:placeholder-shown,\n  li[data-type=control_datetime] [data-wrapper-react=true]:not(.extended) .form-textbox:not(.time-dropdown):placeholder-shown,\n  .appointmentCalendarContainer .currentDate {\n    background-image: url(data:image\/svg+xml;base64,PHN2ZyB3aWR0aD0iMTciIGhlaWdodD0iMTYiIHZpZXdCb3g9IjAgMCAxNyAxNiIgZmlsbD0ibm9uZSIgeG1sbnM9Imh0dHA6Ly93d3cudzMub3JnLzIwMDAvc3ZnIj4KPHBhdGggZD0iTTE1Ljk0ODkgNVYxNS4wMjZDMTUuOTQ4OSAxNS41NjM5IDE1LjUwMjYgMTYgMTQuOTUyMSAxNkgwLjk5NjgwNUMwLjQ0NjI4NSAxNiAwIDE1LjU2MzkgMCAxNS4wMjZWNUgxNS45NDg5Wk00LjE5MjQ1IDExLjQxNjdIMi4zNzQ3NEwyLjI4NTE1IDExLjQyNDdDMi4xMTA3OCAxMS40NTY1IDEuOTY4MDEgMTEuNTc5MiAxLjkwNzUyIDExLjc0MjJMMS44ODQzNyAxMS44MjY4TDEuODc2MzQgMTEuOTE2N1YxMy42NjY3TDEuODg0MzcgMTMuNzU2NUMxLjkxNjAyIDEzLjkzMTUgMi4wMzg0IDE0LjA3NDcgMi4yMDA4MyAxNC4xMzU0TDIuMjg1MTUgMTQuMTU4NkwyLjM3NDc0IDE0LjE2NjdINC4xOTI0NUw0LjI4MjAzIDE0LjE1ODZDNC40NTY0MSAxNC4xMjY5IDQuNTk5MTggMTQuMDA0MSA0LjY1OTY3IDEzLjg0MTFMNC42ODI4MiAxMy43NTY1TDQuNjkwODUgMTMuNjY2N1YxMS45MTY3TDQuNjgyODIgMTEuODI2OEM0LjY1MTE3IDExLjY1MTkgNC41Mjg3OSAxMS41MDg2IDQuMzY2MzUgMTEuNDQ3OUw0LjI4MjAzIDExLjQyNDdMNC4xOTI0NSAxMS40MTY3Wk04Ljg4MzI5IDExLjQxNjdINy4wNjU1OUw2Ljk3NiAxMS40MjQ3QzYuODAxNjIgMTEuNDU2NSA2LjY1ODg1IDExLjU3OTIgNi41OTgzNyAxMS43NDIyTDYuNTc1MjIgMTEuODI2OEw2LjU2NzE5IDExLjkxNjdWMTMuNjY2N0w2LjU3NTIyIDEzLjc1NjVDNi42MDY4NyAxMy45MzE1IDYuNzI5MjUgMTQuMDc0NyA2Ljg5MTY4IDE0LjEzNTRMNi45NzYgMTQuMTU4Nkw3LjA2NTU5IDE0LjE2NjdIOC44ODMyOUw4Ljk3Mjg4IDE0LjE1ODZDOS4xNDcyNiAxNC4xMjY5IDkuMjkwMDMgMTQuMDA0MSA5LjM1MDUxIDEzLjg0MTFMOS4zNzM2NyAxMy43NTY1TDkuMzgxNyAxMy42NjY3VjExLjkxNjdMOS4zNzM2NyAxMS44MjY4QzkuMzQyMDIgMTEuNjUxOSA5LjIxOTY0IDExLjUwODYgOS4wNTcyIDExLjQ0NzlMOC45NzI4OCAxMS40MjQ3TDguODgzMjkgMTEuNDE2N1pNNC4xOTI0NSA2LjgzMzMzSDIuMzc0NzRMMi4yODUxNSA2Ljg0MTM5QzIuMTEwNzggNi44NzMxNCAxLjk2ODAxIDYuOTk1OTEgMS45MDc1MiA3LjE1ODg3TDEuODg0MzcgNy4yNDM0NkwxLjg3NjM0IDcuMzMzMzNWOS4wODMzM0wxLjg4NDM3IDkuMTczMjFDMS45MTYwMiA5LjM0ODE1IDIuMDM4NCA5LjQ5MTM3IDIuMjAwODMgOS41NTIwNUwyLjI4NTE1IDkuNTc1MjhMMi4zNzQ3NCA5LjU4MzMzSDQuMTkyNDVMNC4yODIwMyA5LjU3NTI4QzQuNDU2NDEgOS41NDM1MyA0LjU5OTE4IDkuNDIwNzUgNC42NTk2NyA5LjI1NzhMNC42ODI4MiA5LjE3MzIxTDQuNjkwODUgOS4wODMzM1Y3LjMzMzMzTDQuNjgyODIgNy4yNDM0NkM0LjY1MTE3IDcuMDY4NTIgNC41Mjg3OSA2LjkyNTI5IDQuMzY2MzUgNi44NjQ2MUw0LjI4MjAzIDYuODQxMzlMNC4xOTI0NSA2LjgzMzMzWk04Ljg4MzI5IDYuODMzMzNINy4wNjU1OUw2Ljk3NiA2Ljg0MTM5QzYuODAxNjIgNi44NzMxNCA2LjY1ODg1IDYuOTk1OTEgNi41OTgzNyA3LjE1ODg3TDYuNTc1MjIgNy4yNDM0Nkw2LjU2NzE5IDcuMzMzMzNWOS4wODMzM0w2LjU3NTIyIDkuMTczMjFDNi42MDY4NyA5LjM0ODE1IDYuNzI5MjUgOS40OTEzNyA2Ljg5MTY4IDkuNTUyMDVMNi45NzYgOS41NzUyOEw3LjA2NTU5IDkuNTgzMzNIOC44ODMyOUw4Ljk3Mjg4IDkuNTc1MjhDOS4xNDcyNiA5LjU0MzUzIDkuMjkwMDMgOS40MjA3NSA5LjM1MDUxIDkuMjU3OEw5LjM3MzY3IDkuMTczMjFMOS4zODE3IDkuMDgzMzNWNy4zMzMzM0w5LjM3MzY3IDcuMjQzNDZDOS4zNDIwMiA3LjA2ODUyIDkuMjE5NjQgNi45MjUyOSA5LjA1NzIgNi44NjQ2MUw4Ljk3Mjg4IDYuODQxMzlMOC44ODMyOSA2LjgzMzMzWk0xMy41NzQxIDYuODMzMzNIMTEuNzU2NEwxMS42NjY4IDYuODQxMzlDMTEuNDkyNSA2Ljg3MzE0IDExLjM0OTcgNi45OTU5MSAxMS4yODkyIDcuMTU4ODdMMTEuMjY2MSA3LjI0MzQ2TDExLjI1OCA3LjMzMzMzVjkuMDgzMzNMMTEuMjY2MSA5LjE3MzIxQzExLjI5NzcgOS4zNDgxNSAxMS40MjAxIDkuNDkxMzcgMTEuNTgyNSA5LjU1MjA1TDExLjY2NjggOS41NzUyOEwxMS43NTY0IDkuNTgzMzNIMTMuNTc0MUwxMy42NjM3IDkuNTc1MjhDMTMuODM4MSA5LjU0MzUzIDEzLjk4MDkgOS40MjA3NSAxNC4wNDE0IDkuMjU3OEwxNC4wNjQ1IDkuMTczMjFMMTQuMDcyNSA5LjA4MzMzVjcuMzMzMzNMMTQuMDY0NSA3LjI0MzQ2QzE0LjAzMjkgNy4wNjg1MiAxMy45MTA1IDYuOTI1MjkgMTMuNzQ4IDYuODY0NjFMMTMuNjYzNyA2Ljg0MTM5TDEzLjU3NDEgNi44MzMzM1oiIGZpbGw9IiM1ODY1N0MiLz4KPHBhdGggZD0iTTEzLjA1MjIgMS4xMjVIMTUuMDQ1OEMxNS41OTYzIDEuMTI1IDE2LjA0MjYgMS42MDA3IDE2LjA0MjYgMi4xODc1VjRIMC4wOTM3NVYyLjE4NzVDMC4wOTM3NSAxLjYwMDcgMC41NDAwMzUgMS4xMjUgMS4wOTA1NiAxLjEyNUgzLjA4NDE3VjEuMDYyNUMzLjA4NDE3IDAuNDc1Njk3IDMuNTMwNDUgMCA0LjA4MDk3IDBDNC42MzE0OSAwIDUuMDc3NzggMC40NzU2OTcgNS4wNzc3OCAxLjA2MjVWMS4xMjVIMTEuMDU4NlYxLjA2MjVDMTEuMDU4NiAwLjQ3NTY5NyAxMS41MDQ5IDAgMTIuMDU1NCAwQzEyLjYwNTkgMCAxMy4wNTIyIDAuNDc1Njk3IDEzLjA1MjIgMS4wNjI1VjEuMTI1WiIgZmlsbD0iIzU4NjU3QyIvPgo8L3N2Zz4K);\n  }\n  .form-star-rating-star.Stars {\n    background-image: 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Once completed and submitted emails will be sent to you, your supervisor, and SEIU Healthcare PA with a PDF record of your assignment despite objection.\\nAfter notifying your supervisor, submit this form as soon as possible, to create documentation that you objected prior to any adverse consequences of reported unsafe assignment.\\nThere are questions you might only be able to answer following your shift. Leave those blank and submit the form with the information you have now. You will receive an automated email with a link to edit your responses upon hitting submit. 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Once completed and submitted emails will be sent to you, your supervisor, and SEIU Healthcare PA with a PDF record of your assignment despite objection.<\/p>\n            <p>After notifying your supervisor, submit this form as soon as possible, to create documentation that you objected prior to any adverse consequences of reported unsafe assignment.<\/p>\n            <p><strong>There are questions you might only be able to answer <em>following<\/em> your shift.<\/strong> Leave those blank and submit the form with the information you have now. You will receive an automated email with a link to edit your responses upon hitting submit. <strong>After your shift, go to your email and use that \u201cedit\u201d link to update the form to record what happened during the shift.<\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_3\"><label class=\"form-label form-label-left\" id=\"label_3\" for=\"first_3\" aria-hidden=\"false\"> Your Name<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_3\" class=\"form-input jf-required\" data-layout=\"full\">\n          <div data-wrapper-react=\"true\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\"><input type=\"text\" id=\"first_3\" name=\"q3_yourName[first]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_3 given-name\" size=\"10\" data-component=\"first\" aria-labelledby=\"label_3 sublabel_3_first\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"first_3\" id=\"sublabel_3_first\" style=\"min-height:13px\">First Name<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\"><input type=\"text\" id=\"last_3\" name=\"q3_yourName[last]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_3 family-name\" size=\"15\" data-component=\"last\" aria-labelledby=\"label_3 sublabel_3_last\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"last_3\" id=\"sublabel_3_last\" style=\"min-height:13px\">Last Name<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_4\"><label class=\"form-label form-label-left\" id=\"label_4\" for=\"input_4\" aria-hidden=\"false\"> Your Email<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_4\" class=\"form-input jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"email\" id=\"input_4\" name=\"q4_yourEmail\" class=\"form-textbox validate[required, Email]\" data-defaultvalue=\"\" autoComplete=\"section-input_4 email\" style=\"width:310px\" size=\"310\" data-component=\"email\" aria-labelledby=\"label_4 sublabel_input_4\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_4\" id=\"sublabel_input_4\" style=\"min-height:13px\">example@example.com<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_5\"><label class=\"form-label form-label-left\" id=\"label_5\" for=\"input_5_full\"> Your Cell Phone Number <\/label>\n        <div id=\"cid_5\" class=\"form-input\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" id=\"input_5_full\" name=\"q5_yourCell[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[Fill Mask]\" data-defaultvalue=\"\" autoComplete=\"section-input_5 tel-national\" style=\"width:310px\" data-masked=\"true\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_5 sublabel_5_masked\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_5_full\" id=\"sublabel_5_masked\" style=\"min-height:13px\">Please enter a valid phone number.<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_6\"><label class=\"form-label form-label-left\" id=\"label_6\" for=\"input_6\" aria-hidden=\"false\"> Job Title<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_6\" class=\"form-input jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_6\" name=\"q6_jobTitle\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_6\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_7\"><label class=\"form-label form-label-left\" id=\"label_7\" for=\"input_7\" aria-hidden=\"false\"> Unit\/Department<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_7\" class=\"form-input jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_7\" name=\"q7_typeA7\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Unit\/Department\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Anesthesia Unit\/Postanesthesia Recovery Unit\">Anesthesia Unit\/Postanesthesia Recovery Unit<\/option>\n            <option value=\"Burn Unit\">Burn Unit<\/option>\n            <option value=\"Critical Care Unit\">Critical Care Unit<\/option>\n            <option value=\"Emergency Department\">Emergency Department<\/option>\n            <option value=\"Intensive Care Unit\">Intensive Care Unit<\/option>\n            <option value=\"Labor and Delivery Suite\">Labor and Delivery Suite<\/option>\n            <option value=\"Medical\/Surgical\">Medical\/Surgical<\/option>\n            <option value=\"Neonatal Intensive Care Unit\">Neonatal Intensive Care Unit<\/option>\n            <option value=\"Well Baby Nursery\">Well Baby Nursery<\/option>\n            <option value=\"Newborn Nursery \">Newborn Nursery <\/option>\n            <option value=\"Operating Room\">Operating Room<\/option>\n            <option value=\"Patients Receiving Conscious Sedation\">Patients Receiving Conscious Sedation<\/option>\n            <option value=\"Pediatrics\">Pediatrics<\/option>\n            <option value=\"Prenatal Service\">Prenatal Service<\/option>\n            <option value=\"Presurgical and Admissions Units\">Presurgical and Admissions Units<\/option>\n            <option value=\"Ambulatory Surgical Units\">Ambulatory Surgical Units<\/option>\n            <option value=\"Psychiatric\">Psychiatric<\/option>\n            <option value=\"Rehabilitation\">Rehabilitation<\/option>\n            <option value=\"Skilled Nursing Unit \">Skilled Nursing Unit <\/option>\n            <option value=\"Speciality Units\">Speciality Units<\/option>\n            <option value=\"Step Down, Immediate Care Unit\">Step Down, Immediate Care Unit<\/option>\n            <option value=\"Telemetry\">Telemetry<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_autocomp\" id=\"id_57\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_57\" for=\"input_57\" aria-hidden=\"false\"> Facility<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_57\" class=\"form-input-wide jf-required\" data-layout=\"full\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_57\" name=\"q57_facility57\" class=\"form-textbox validate[required] form-autocomplete\" data-fuzzysearch=\"Yes\" data-maxmatches=\"100\" data-defaultvalue=\"\" autoComplete=\"nope\" size=\"20\" data-component=\"autocomplete\" aria-labelledby=\"label_57\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_57\" id=\"sublabel_input_57\" style=\"min-height:13px\">Type in your employing facility, please select a match from the dropdown if it appears.<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_50\"><label class=\"form-label form-label-top\" id=\"label_50\" aria-hidden=\"false\"> Are you a member of SEIU Healthcare PA? <\/label>\n        <div id=\"cid_50\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_50\" data-component=\"radio\"><span class=\"form-radio-item\"><span 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Shift<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_9\" class=\"form-input jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_9\" name=\"q9_typeA9\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_9\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_10\"><label class=\"form-label form-label-left\" id=\"label_10\" for=\"lite_mode_10\" aria-hidden=\"false\"> Date<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_10\" class=\"form-input jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_10\" name=\"q10_date[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_10 sublabel_10_month\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"month_10\" id=\"sublabel_10_month\" style=\"min-height:13px\">Month<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_10\" name=\"q10_date[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_10 sublabel_10_day\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"day_10\" id=\"sublabel_10_day\" style=\"min-height:13px\">Day<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_10\" name=\"q10_date[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_10 sublabel_10_year\" \/><label class=\"form-sub-label\" for=\"year_10\" id=\"sublabel_10_year\" style=\"min-height:13px\">Year<\/label><\/span><\/div><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_10\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"\" value=\"\" required=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"MM-DD-YYYY\" data-placeholder=\"MM-DD-YYYY\" autoComplete=\"off\" aria-labelledby=\"label_10 sublabel_10_litemode\" \/><img class=\" newDefaultTheme-dateIcon icon-liteMode\" alt=\"Pick a Date\" id=\"input_10_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v2\" \/><label class=\"form-sub-label\" for=\"lite_mode_10\" id=\"sublabel_10_litemode\" style=\"min-height:13px\">Date<\/label><\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_time\" id=\"id_11\"><label class=\"form-label form-label-left\" id=\"label_11\" for=\"input_11_hourSelect\" aria-hidden=\"false\"> Time<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_11\" class=\"form-input jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div class=\"time-wrapper\"><span class=\"form-sub-label-container hasAMPM\" style=\"vertical-align:top\"><input type=\"text\" class=\"time-dropdown form-textbox validate[required, time]\" id=\"input_11_timeInput\" name=\"q11_time[timeInput]\" required=\"\" placeholder=\"HH : MM\" aria-labelledby=\"label_11 sublabel_11_hour\" data-mask=\"hh:MM\" value=\"\" autoComplete=\"off\" data-version=\"v2\" \/><input type=\"hidden\" class=\"form-hidden-time\" id=\"input_11_hourSelect\" name=\"q11_time[hourSelect]\" \/><input type=\"hidden\" class=\"form-hidden-time\" id=\"input_11_minuteSelect\" name=\"q11_time[minuteSelect]\" \/><label data-seperate-translate=\"true\" class=\"form-sub-label\" for=\"input_11_timeInput\" id=\"sublabel_11_hour\" style=\"min-height:13px\">Hour Minutes<\/label><\/span><\/div>\n            <div class=\"time-wrapper\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><select class=\"time-dropdown form-dropdown validate[required]\" id=\"input_11_ampm\" name=\"q11_time[ampm]\" data-component=\"time-ampm\" required=\"\" aria-labelledby=\"label_11 sublabel_11_ampm\" autoComplete=\"off\">\n                  <option selected=\"\" value=\"AM\">AM<\/option>\n                  <option value=\"PM\">PM<\/option>\n                <\/select><label class=\"form-sub-label\" for=\"input_11_ampm\" id=\"sublabel_11_ampm\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\">AM\/PM Option<\/label><\/span><\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_58\">\n        <div id=\"cid_58\" class=\"form-input-wide\" data-layout=\"full\">\n          <div id=\"text_58\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <h2><span style=\"color: #8c1a10;\">Before proceeding, you must notify your supervisor of unsafe conditions. This step is required prior to documentation and submission of this form.<\/span><\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_13\"><label class=\"form-label form-label-top\" id=\"label_13\" for=\"input_13_0\" aria-hidden=\"false\"> Have you notified your supervisor of unsafe conditions?<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_13\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_13\" class=\"form-radio validate[required]\" id=\"input_13_0\" name=\"q13_haveYou\" value=\"Yes, I have notified my supervisor of unsafe conditions\" required=\"\" \/><label id=\"label_input_13_0\" for=\"input_13_0\">Yes, I have notified my supervisor of unsafe conditions<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_14\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_14\" class=\"form-header\" data-component=\"header\">SUPERVISOR\/OTHER PERSON (Superior) YOU REPORTED UNSAFE CONDITIONS TO<\/h2>\n            <div id=\"subHeader_14\" class=\"form-subHeader\">If the supervisor makes a statement, document it and quote exactly. If they refuse to call back or answer document as well.<\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_15\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_15\" for=\"first_15\" aria-hidden=\"false\"> Name of Supervisor<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div data-wrapper-react=\"true\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\"><input type=\"text\" id=\"first_15\" name=\"q15_nameOf[first]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_15 given-name\" size=\"10\" data-component=\"first\" aria-labelledby=\"label_15 sublabel_15_first\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"first_15\" id=\"sublabel_15_first\" style=\"min-height:13px\">First Name<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\"><input type=\"text\" id=\"last_15\" name=\"q15_nameOf[last]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_15 family-name\" size=\"15\" data-component=\"last\" aria-labelledby=\"label_15 sublabel_15_last\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"last_15\" id=\"sublabel_15_last\" style=\"min-height:13px\">Last Name<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_16\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_16\" for=\"input_16\" aria-hidden=\"false\"> Supervisor Title<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_16\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_16\" name=\"q16_supervisorTitle\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_16\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_48\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_48\" for=\"input_48\" aria-hidden=\"false\"> Supervisor Email<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_48\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"email\" id=\"input_48\" name=\"q48_supervisorEmail\" class=\"form-textbox validate[required, Email]\" data-defaultvalue=\"\" autoComplete=\"section-input_48 email\" style=\"width:310px\" size=\"310\" data-component=\"email\" aria-labelledby=\"label_48 sublabel_input_48\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_48\" id=\"sublabel_input_48\" style=\"min-height:13px\">example@example.com<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_18\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_18\" for=\"lite_mode_18\" aria-hidden=\"false\"> Date of report to supervisor<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_18\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_18\" name=\"q18_dateOf[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_18 sublabel_18_month\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"month_18\" id=\"sublabel_18_month\" style=\"min-height:13px\">Month<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_18\" name=\"q18_dateOf[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_18 sublabel_18_day\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"day_18\" id=\"sublabel_18_day\" style=\"min-height:13px\">Day<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_18\" name=\"q18_dateOf[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_18 sublabel_18_year\" \/><label class=\"form-sub-label\" for=\"year_18\" id=\"sublabel_18_year\" style=\"min-height:13px\">Year<\/label><\/span><\/div><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_18\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"\" value=\"\" required=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"MM-DD-YYYY\" data-placeholder=\"MM-DD-YYYY\" autoComplete=\"off\" aria-labelledby=\"label_18 sublabel_18_litemode\" \/><img class=\" newDefaultTheme-dateIcon icon-liteMode\" alt=\"Pick a Date\" id=\"input_18_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v2\" \/><label class=\"form-sub-label\" for=\"lite_mode_18\" id=\"sublabel_18_litemode\" style=\"min-height:13px\">Date<\/label><\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_time\" id=\"id_19\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_19\" for=\"input_19_hourSelect\" aria-hidden=\"false\"> Time of report to supervisor<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_19\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div class=\"time-wrapper\"><span class=\"form-sub-label-container hasAMPM\" style=\"vertical-align:top\"><input type=\"text\" class=\"time-dropdown form-textbox validate[required, time]\" id=\"input_19_timeInput\" name=\"q19_timeOf[timeInput]\" required=\"\" placeholder=\"HH : MM\" aria-labelledby=\"label_19 sublabel_19_hour\" data-mask=\"hh:MM\" value=\"\" autoComplete=\"off\" data-version=\"v2\" \/><input type=\"hidden\" class=\"form-hidden-time\" id=\"input_19_hourSelect\" name=\"q19_timeOf[hourSelect]\" \/><input type=\"hidden\" class=\"form-hidden-time\" id=\"input_19_minuteSelect\" name=\"q19_timeOf[minuteSelect]\" \/><label data-seperate-translate=\"true\" class=\"form-sub-label\" for=\"input_19_timeInput\" id=\"sublabel_19_hour\" style=\"min-height:13px\">Hour Minutes<\/label><\/span><\/div>\n            <div class=\"time-wrapper\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><select class=\"time-dropdown form-dropdown validate[required]\" id=\"input_19_ampm\" name=\"q19_timeOf[ampm]\" data-component=\"time-ampm\" required=\"\" aria-labelledby=\"label_19 sublabel_19_ampm\" autoComplete=\"off\">\n                  <option selected=\"\" value=\"AM\">AM<\/option>\n                  <option value=\"PM\">PM<\/option>\n                <\/select><label class=\"form-sub-label\" for=\"input_19_ampm\" id=\"sublabel_19_ampm\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\">AM\/PM Option<\/label><\/span><\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textarea\" id=\"id_20\"><label class=\"form-label form-label-top\" id=\"label_20\" for=\"input_20\" aria-hidden=\"false\"> Their response, or failure to respond<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide jf-required\" data-layout=\"full\"> <textarea id=\"input_20\" class=\"form-textarea validate[required]\" name=\"q20_theirResponse\" style=\"width:648px;height:163px\" data-component=\"textarea\" required=\"\" aria-labelledby=\"label_20\"><\/textarea> <\/div>\n      <\/li>\n      <li id=\"cid_23\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_23\" class=\"form-header\" data-component=\"header\">REASON for ADO<\/h2>\n            <div id=\"subHeader_23\" class=\"form-subHeader\">Check as many issues as are applicable. Add other reason(s) for objection to assignment if not already there, \u200b\u200bfor example suicide precautions, 1:1; therapeutic hypothermia protocol, 1:1; etc.<\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_21\"><label class=\"form-label form-label-top\" id=\"label_21\" aria-hidden=\"false\"> REASON for ADO (check all that apply)<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_21\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_21\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_0\" name=\"q21_name21[]\" value=\"Inadequate staff for acuity of patients, including support staff\" required=\"\" \/><label id=\"label_input_21_0\" for=\"input_21_0\">Inadequate staff for acuity of patients, including support staff<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_1\" name=\"q21_name21[]\" value=\"I was given an assignment which posed a potential threat to the health and safety of   patients and staff\" required=\"\" \/><label id=\"label_input_21_1\" for=\"input_21_1\">I was given an assignment which posed a potential threat to the health and safety of patients and staff<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_2\" name=\"q21_name21[]\" value=\"I was not trained or experienced in the area\" required=\"\" \/><label id=\"label_input_21_2\" for=\"input_21_2\">I was not trained or experienced in the area<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_3\" name=\"q21_name21[]\" value=\"The unit was staffed with excessive agency\/registry\/staff from another units (non-unit)\" required=\"\" \/><label id=\"label_input_21_3\" for=\"input_21_3\">The unit was staffed with excessive agency\/registry\/staff from another units (non-unit)<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_4\" name=\"q21_name21[]\" value=\"Lack of equipment or unavailable supplies to provide safe patient care\" required=\"\" \/><label id=\"label_input_21_4\" for=\"input_21_4\">Lack of equipment or unavailable supplies to provide safe patient care<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_5\" name=\"q21_name21[]\" value=\"New patients were transferred or admitted to the unit without adequate staff\" required=\"\" \/><label id=\"label_input_21_5\" for=\"input_21_5\">New patients were transferred or admitted to the unit without adequate staff<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_6\" name=\"q21_name21[]\" value=\"Unable to delegate as staff assigned to unit does not have qualifications\/experience for unit.\" required=\"\" \/><label id=\"label_input_21_6\" for=\"input_21_6\">Unable to delegate as staff assigned to unit does not have qualifications\/experience for unit.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_7\" name=\"q21_name21[]\" value=\"Staff involuntarily forced to work beyond scheduled hours*\" required=\"\" \/><label id=\"label_input_21_7\" for=\"input_21_7\">Staff involuntarily forced to work beyond scheduled hours*<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_21\" class=\"form-checkbox validate[required]\" id=\"input_21_8\" name=\"q21_name21[]\" value=\"Equipment malfunction (i.e. multiple over rides)\" required=\"\" \/><label id=\"label_input_21_8\" for=\"input_21_8\">Equipment malfunction (i.e. multiple over rides)<\/label><\/span><span class=\"form-checkbox-item formCheckboxOther\" style=\"clear:left\"><input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q21_name21[other]\" id=\"other_21\" value=\"other\" tabindex=\"0\" aria-label=\"Other\" \/><label id=\"label_other_21\" style=\"text-indent:0\" for=\"other_21\">Other<\/label><span id=\"other_21_input\" class=\"other-input-container\" style=\"display:none\"><input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q21_name21[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_21\" data-placeholder=\"Please type another option here\" placeholder=\"Please type another option here\" \/><\/span><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_44\"><label class=\"form-label form-label-top\" id=\"label_44\" for=\"input_44\" aria-hidden=\"false\"> Other Reason for ADO <\/label>\n        <div id=\"cid_44\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_44\" class=\"form-textarea\" name=\"q44_otherReason44\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_44\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_59\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_59\" aria-hidden=\"false\"> Were you mandated to work beyond your scheduled shift in violation of Act 102 and\/or in violation of your union contract? <\/label>\n        <div id=\"cid_59\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_59\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_59\" class=\"form-checkbox\" id=\"input_59_0\" name=\"q59_wereYou[]\" value=\"Yes\" \/><label id=\"label_input_59_0\" for=\"input_59_0\">Yes<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_59\" class=\"form-checkbox\" id=\"input_59_1\" name=\"q59_wereYou[]\" value=\"No\" \/><label id=\"label_input_59_1\" for=\"input_59_1\">No<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_59\" class=\"form-checkbox\" id=\"input_59_2\" name=\"q59_wereYou[]\" value=\"Uncertain\" \/><label id=\"label_input_59_2\" for=\"input_59_2\">Uncertain<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_24\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_24\" class=\"form-header\" data-component=\"header\">Patient Census<\/h2>\n            <div id=\"subHeader_24\" class=\"form-subHeader\">Please note that you will receive an email with a link that will allow you to update your responses in the middle and\/or at the end of your shift.<\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_number\" id=\"id_26\"><label class=\"form-label form-label-left\" id=\"label_26\" for=\"input_26\" aria-hidden=\"false\"> Patients at start of shift<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_26\" class=\"form-input jf-required\" data-layout=\"half\"> <input type=\"number\" id=\"input_26\" name=\"q26_patientsAt\" data-type=\"input-number\" class=\" form-number-input form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_26\" required=\"\" step=\"any\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_number\" id=\"id_27\"><label class=\"form-label form-label-left\" id=\"label_27\" for=\"input_27\" aria-hidden=\"false\"> Patients at end of shift <\/label>\n        <div id=\"cid_27\" class=\"form-input\" data-layout=\"half\"> <input type=\"number\" id=\"input_27\" name=\"q27_patientsAt27\" data-type=\"input-number\" class=\" form-number-input form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_27\" step=\"any\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_number\" id=\"id_28\"><label class=\"form-label form-label-left\" id=\"label_28\" for=\"input_28\" aria-hidden=\"false\"> Unit capacity <\/label>\n        <div id=\"cid_28\" class=\"form-input\" data-layout=\"half\"> <input type=\"number\" id=\"input_28\" name=\"q28_unitCapacity\" data-type=\"input-number\" class=\" form-number-input form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_28\" step=\"any\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_number\" id=\"id_29\"><label class=\"form-label form-label-left\" id=\"label_29\" for=\"input_29\" aria-hidden=\"false\"> # Admissions <\/label>\n        <div id=\"cid_29\" class=\"form-input\" data-layout=\"half\"> <input type=\"number\" id=\"input_29\" name=\"q29_Admissions\" data-type=\"input-number\" class=\" form-number-input form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_29\" step=\"any\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_number\" id=\"id_30\"><label class=\"form-label form-label-left\" id=\"label_30\" for=\"input_30\" aria-hidden=\"false\"> # Discharges <\/label>\n        <div id=\"cid_30\" class=\"form-input\" data-layout=\"half\"> <input type=\"number\" id=\"input_30\" name=\"q30_Discharges\" data-type=\"input-number\" class=\" form-number-input form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_30\" step=\"any\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_number\" id=\"id_47\"><label class=\"form-label form-label-left\" id=\"label_47\" for=\"input_47\" aria-hidden=\"false\"> Codes\/RRT <\/label>\n        <div id=\"cid_47\" class=\"form-input\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"number\" id=\"input_47\" name=\"q47_codesrrt\" data-type=\"input-number\" class=\" form-number-input form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_47 sublabel_input_47\" step=\"any\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_47\" id=\"sublabel_input_47\" style=\"min-height:13px\">(i.e. Rapid Response Team, code purple)<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_number\" id=\"id_31\"><label class=\"form-label form-label-left\" id=\"label_31\" for=\"input_31\" aria-hidden=\"false\"> # 1:1 <\/label>\n        <div id=\"cid_31\" class=\"form-input\" data-layout=\"half\"> <input type=\"number\" id=\"input_31\" name=\"q31_11\" data-type=\"input-number\" class=\" form-number-input form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_31\" step=\"any\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_number\" id=\"id_33\"><label class=\"form-label form-label-left\" id=\"label_33\" for=\"input_33\" aria-hidden=\"false\"> # Fall Risks <\/label>\n        <div id=\"cid_33\" class=\"form-input\" data-layout=\"half\"> <input type=\"number\" id=\"input_33\" name=\"q33_Fall\" data-type=\"input-number\" class=\" form-number-input form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" placeholder=\"ex: 23\" data-component=\"number\" aria-labelledby=\"label_33\" step=\"any\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_34\"><label class=\"form-label form-label-left\" id=\"label_34\" for=\"input_34\" aria-hidden=\"false\"> Other <\/label>\n        <div id=\"cid_34\" class=\"form-input\" data-layout=\"half\"> <input type=\"text\" id=\"input_34\" name=\"q34_other\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_34\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_matrix\" id=\"id_25\"><label class=\"form-label form-label-top\" id=\"label_25\" for=\"input_25\" aria-hidden=\"false\"> Staffing Numbers <\/label>\n        <div id=\"cid_25\" class=\"form-input-wide\" data-layout=\"full\">\n          <table summary=\"\" aria-labelledby=\"label_25\" cellPadding=\"4\" cellSpacing=\"0\" class=\"form-matrix-table\" data-component=\"matrix\">\n            <tr class=\"form-matrix-tr form-matrix-header-tr\">\n              <th class=\"form-matrix-th\" style=\"border:none\">\u00a0<\/th>\n              <th scope=\"col\" class=\"form-matrix-headers form-matrix-column-headers form-matrix-column_0\"><label id=\"label_25_col_0\">Start of shift<\/label><\/th>\n              <th scope=\"col\" class=\"form-matrix-headers form-matrix-column-headers form-matrix-column_1\"><label id=\"label_25_col_1\">Halfway though<\/label><\/th>\n              <th scope=\"col\" class=\"form-matrix-headers form-matrix-column-headers form-matrix-column_2\"><label id=\"label_25_col_2\">End of Shift<\/label><\/th>\n            <\/tr>\n            <tr class=\"form-matrix-tr form-matrix-value-tr\" aria-labelledby=\"label_25 label_25_row_0\">\n              <th scope=\"row\" class=\"form-matrix-headers form-matrix-row-headers\"><label id=\"label_25_row_0\">Patients assigned to you<\/label><\/th>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_0_0\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[0][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_0 label_25_row_0\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_0_1\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[0][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_1 label_25_row_0\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_0_2\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[0][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_2 label_25_row_0\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n            <\/tr>\n            <tr class=\"form-matrix-tr form-matrix-value-tr\" aria-labelledby=\"label_25 label_25_row_1\">\n              <th scope=\"row\" class=\"form-matrix-headers form-matrix-row-headers\"><label id=\"label_25_row_1\">Patients in Department<br \/><\/label><\/th>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_1_0\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[1][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_0 label_25_row_1\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_1_1\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[1][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_1 label_25_row_1\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_1_2\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[1][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_2 label_25_row_1\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n            <\/tr>\n            <tr class=\"form-matrix-tr form-matrix-value-tr\" aria-labelledby=\"label_25 label_25_row_2\">\n              <th scope=\"row\" class=\"form-matrix-headers form-matrix-row-headers\"><label id=\"label_25_row_2\">RN<br \/><\/label><\/th>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_2_0\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[2][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_0 label_25_row_2\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_2_1\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[2][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_1 label_25_row_2\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_2_2\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[2][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_2 label_25_row_2\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n            <\/tr>\n            <tr class=\"form-matrix-tr form-matrix-value-tr\" aria-labelledby=\"label_25 label_25_row_3\">\n              <th scope=\"row\" class=\"form-matrix-headers form-matrix-row-headers\"><label id=\"label_25_row_3\">LPN<br \/><\/label><\/th>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_3_0\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[3][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_0 label_25_row_3\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_3_1\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[3][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_1 label_25_row_3\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_3_2\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[3][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_2 label_25_row_3\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n            <\/tr>\n            <tr class=\"form-matrix-tr form-matrix-value-tr\" aria-labelledby=\"label_25 label_25_row_4\">\n              <th scope=\"row\" class=\"form-matrix-headers form-matrix-row-headers\"><label id=\"label_25_row_4\">AIDE<br \/><\/label><\/th>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_4_0\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[4][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_0 label_25_row_4\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_4_1\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[4][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_1 label_25_row_4\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_4_2\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[4][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_2 label_25_row_4\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n            <\/tr>\n            <tr class=\"form-matrix-tr form-matrix-value-tr\" aria-labelledby=\"label_25 label_25_row_5\">\n              <th scope=\"row\" class=\"form-matrix-headers form-matrix-row-headers\"><label id=\"label_25_row_5\">CLERK\/SECRETARY<\/label><\/th>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_5_0\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[5][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_0 label_25_row_5\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_5_1\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[5][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_1 label_25_row_5\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_5_2\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[5][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_2 label_25_row_5\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n            <\/tr>\n            <tr class=\"form-matrix-tr form-matrix-value-tr\" aria-labelledby=\"label_25 label_25_row_6\">\n              <th scope=\"row\" class=\"form-matrix-headers form-matrix-row-headers\"><label id=\"label_25_row_6\">OTHER PROFESSIONAL\/TECHNICAL<\/label><\/th>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_6_0\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[6][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_0 label_25_row_6\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_6_1\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[6][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_1 label_25_row_6\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n              <td class=\"form-matrix-values\"><input type=\"number\" id=\"input_25_6_2\" class=\"form-number-input form-textbox\" name=\"q25_staffingNumbers[6][]\" style=\"width:100%;box-sizing:border-box\" size=\"5\" value=\"\" aria-labelledby=\"label_25_col_2 label_25_row_6\" step=\"any\" aria-label=\"Cells Numeric Text Box\" \/><\/td>\n            <\/tr>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_41\">\n        <div id=\"cid_41\" class=\"form-input-wide\" data-layout=\"full\">\n          <div id=\"text_41\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <h2>Statement of Problem<\/h2>\n            <p>Include any and all factors that contributed to the assignment despite objection. Be Specific!! The reader must be able to understand the entire situation from your written report. You will receive an email with a link that will allow your responses to be edited.<\/p>\n            <p>When completing this form, do not disclose any protected health information about patients. This form may be viewable to your union and others and disclosure of PHI on this form may constitute a violation of HIPAA.<\/p>\n            <p>Protected health information includes: patient names, DOBs, SSNs, etc...<\/p>\n            <p><span style=\"color: #ea3223; background-color: #fffe54;\">DO <strong>NOT<\/strong> USE PATIENTS' NAMES! DO NOT USE MEDICAL RECORD NUMBERS!<\/span><\/p>\n            <p><strong>Do<\/strong> use diagnosis; procedures; issues; treatments; isolations; additional responsibilities (codes, traumas, transport, etc.) or anything else that is pertinent.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textarea\" id=\"id_42\"><label class=\"form-label form-label-top\" id=\"label_42\" for=\"input_42\" aria-hidden=\"false\"> Statement<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_42\" class=\"form-input-wide jf-required\" data-layout=\"full\"> <textarea id=\"input_42\" class=\"form-textarea validate[required]\" name=\"q42_statement\" style=\"width:648px;height:163px\" data-component=\"textarea\" required=\"\" aria-labelledby=\"label_42\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_45\"><label class=\"form-label form-label-top\" id=\"label_45\" for=\"input_45_0\" aria-hidden=\"false\"> Confirmation<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_45\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_45\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_45\" class=\"form-radio validate[required]\" id=\"input_45_0\" name=\"q45_confirmation\" value=\"As a patient advocate, in accordance with the Pennsylvania Nurse Practice Act, this is to confirm that I notified you, in my professional judgment, that today\u2019s assignment is unsafe and places patients and staff at risk.  I hereby give notice to my employer of the above facts and indicate that for the reasons listed that \u2013 full responsibility for the consequences of this assignment rests with the employer.  I will, under protest, attempt to carry out the assignment to the best of my ability. Copies of this form may be provided to any and all appropriate State and Federal agencies. SEIU Healthcare Pennsylvania will use it to facilitate resolution of the problem and might be used for research and advocacy purposes.\" required=\"\" \/><label id=\"label_input_45_0\" for=\"input_45_0\">As a patient advocate, in accordance with the Pennsylvania Nurse Practice Act, this is to confirm that I notified you, in my professional judgment, that today\u2019s assignment is unsafe and places patients and staff at risk. I hereby give notice to my employer of the above facts and indicate that for the reasons listed that \u2013 full responsibility for the consequences of this assignment rests with the employer. I will, under protest, attempt to carry out the assignment to the best of my ability. Copies of this form may be provided to any and all appropriate State and Federal agencies. SEIU Healthcare Pennsylvania will use it to facilitate resolution of the problem and might be used for research and advocacy purposes.<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_signature\" id=\"id_46\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_46\" for=\"input_46\" aria-hidden=\"false\"> Signature<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_46\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div id=\"signature_pad_46\" class=\"signature-pad-wrapper\">\n              <div data-wrapper-react=\"true\">\n                <!--[if IE 7]><script type=\"text\/javascript\" src=\"\/js\/vendor\/json2.js\"><\/script><![endif]-->\n              <\/div>\n              <div class=\"signature-line signature-wrapper signature-placeholder\" data-component=\"signature\">\n                <div id=\"sig_pad_46\" data-width=\"310\" data-height=\"114\" data-id=\"46\" data-required=\"true\" class=\"pad validate[required]\" aria-labelledby=\"label_46\"><\/div><input type=\"hidden\" name=\"q46_signature\" class=\"output4\" id=\"input_46\" \/>\n              <\/div>\n              <aside class=\"signature-pad-aside\"><span class=\"clear-pad-btn clear-pad\" role=\"button\" tabindex=\"0\">Clear<\/span><\/aside>\n            <\/div>\n            <div data-wrapper-react=\"true\">\n              <script type=\"text\/javascript\">\n                window.signatureForm = true\n              <\/script>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\" data-layout=\"full\">\n          <div data-align=\"auto\" class=\"form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField\"><button id=\"input_2\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField\" data-component=\"button\" data-content=\"\">Submit<\/button><\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">Should be Empty: <input type=\"text\" name=\"website\" value=\"\" type=\"hidden\" \/><\/li>\n    <\/ul>\n  <\/div>\n  <script>\n    JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <script>\n    JotForm.poweredByText = \"Powered by Jotform\";\n  <\/script><input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"221086844553055\" \/>\n  <script type=\"text\/javascript\">\n    var all_spc = document.querySelectorAll(\"form[id='221086844553055'] .si\" + \"mple\" + \"_spc\");\n    for (var i = 0; i < all_spc.length; i++)\n    {\n      all_spc[i].value = \"221086844553055-221086844553055\";\n    }\n  <\/script>\n<\/form><\/body>\n<\/html><script type=\"text\/javascript\">JotForm.isNewSACL=true;<\/script>","Assignment Despite Objection",Array);var permittedDomains=[];try{var renderURLDomain=new URL("https://form.jotform.com/221086844553055").hostname;permittedDomains=[renderURLDomain];}catch(e){permittedDomains=['jotform.com','jotform.pro'];}
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