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(You will automatically receive a confirmation email with your responses.)\",\"type\":\"control_dropdown\"},{\"name\":\"input44\",\"qid\":\"44\",\"text\":\"As a patient advocate, in accordance with the California Nurse Practice Act, I will send this completed form to my supervisor to notify hospital administrators, as well as to any other relevant parties. I submit that, in my professional judgement, today's assignment and\\u002For other workplace conditions are not in accordance with California's Title 22 regulations and raise patient safety concerns.\",\"type\":\"control_text\"},{\"description\":\"\",\"name\":\"concernviolation45\",\"qid\":\"45\",\"text\":\"Due to RNs being out of ratio, the following occurred (select all that apply):  \",\"type\":\"control_checkbox\"},null,{\"description\":\"\",\"name\":\"describeThe\",\"qid\":\"47\",\"text\":\"Describe the acuity using the options below (select all that apply):\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"indicateThe\",\"qid\":\"48\",\"subLabel\":\"\",\"text\":\"Indicate the type of unit that you work in and the location of your unit (for example \\\"Tele, 2 South\\\" or \\\"ICU, 2nd Floor\\\"):\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"patientRoom\",\"qid\":\"49\",\"subLabel\":\"\",\"text\":\"Patient Room Number\",\"type\":\"control_textbox\"},null,{\"description\":\"\",\"name\":\"doYou\",\"qid\":\"51\",\"subLabel\":\"\",\"text\":\"Do you give SEIU 121RN permission to forward this report to the California Department of Public Health (CDPH)?\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"ifYou\",\"qid\":\"52\",\"subLabel\":\"\",\"text\":\"If you selected \\\"other hospital\\\" please list below\",\"type\":\"control_textbox\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" onsubmit=\"return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();\" action=\"https:\/\/submit.jotform.com\/submit\/222687067615059\" method=\"post\" name=\"form_222687067615059\" id=\"222687067615059\" accept-charset=\"utf-8\" autocomplete=\"on\"><input type=\"hidden\" name=\"formID\" value=\"222687067615059\" \/><input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/><input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/><input type=\"hidden\" id=\"jsExecutionTracker\" name=\"jsExecutionTracker\" value=\"build-date-1709073069791\" \/><input type=\"hidden\" id=\"submitSource\" name=\"submitSource\" value=\"unknown\" \/><input type=\"hidden\" id=\"buildDate\" name=\"buildDate\" value=\"1709073069791\" \/>\n  <div id=\"formCoverLogo\" style=\"margin-bottom:10px\" class=\"form-cover-wrapper form-has-cover form-page-cover-image-align-center\">\n    <div class=\"form-page-cover-image-wrapper\" style=\"max-width:752px\"><img src=\"https:\/\/www.jotform.com\/uploads\/weissh\/form_files\/750%20px%20seiu121RNlogoNew.63326587a7e914.32590877.jpg\" class=\"form-page-cover-image\" width=\"350\" aria-label=\"Form Logo\" style=\"aspect-ratio:350\/71\" \/><\/div>\n  <\/div>\n  <div role=\"main\" class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_1\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-large\">\n          <div class=\"header-text httac htvam\">\n            <h1 id=\"header_1\" class=\"form-header\" data-component=\"header\">Patient Safety Reporting Form (ADO) <\/h1>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_4\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_4\" for=\"first_4\" aria-hidden=\"false\"> Name<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_4\" 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_4\" name=\"q4_name[first]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_4 given-name\" size=\"10\" data-component=\"first\" aria-labelledby=\"label_4 sublabel_4_first\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"first_4\" id=\"sublabel_4_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_4\" name=\"q4_name[last]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_4 family-name\" size=\"15\" data-component=\"last\" aria-labelledby=\"label_4 sublabel_4_last\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"last_4\" id=\"sublabel_4_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_10\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_10\" for=\"input_10\" aria-hidden=\"false\"> Email (do not use work email address)<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"email\" id=\"input_10\" name=\"q10_emaildo\" class=\"form-textbox validate[required, Email]\" data-defaultvalue=\"\" autoComplete=\"section-input_10 email\" style=\"width:310px\" size=\"310\" data-component=\"email\" aria-labelledby=\"label_10 sublabel_input_10\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_10\" id=\"sublabel_input_10\" style=\"min-height:13px\">example@example.com<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_11\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_11\" for=\"input_11_full\"> Phone Number <\/label>\n        <div id=\"cid_11\" class=\"form-input-wide\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" id=\"input_11_full\" name=\"q11_phoneNumber[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[Fill Mask]\" data-defaultvalue=\"\" autoComplete=\"section-input_11 tel-national\" style=\"width:310px\" data-masked=\"true\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_11 sublabel_11_masked\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_11_full\" id=\"sublabel_11_masked\" style=\"min-height:13px\">By providing my mobile phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and\/or text message me on my mobile phone on a periodic basis. SE IU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_13\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_13\" for=\"input_13\" aria-hidden=\"false\"> Department\/Unit<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_13\" name=\"q13_departmentunit\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_13\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_48\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_48\" for=\"input_48\" aria-hidden=\"false\"> Indicate the type of unit that you work in and the location of your unit (for example &quot;Tele, 2 South&quot; or &quot;ICU, 2nd Floor&quot;):<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_48\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_48\" name=\"q48_indicateThe\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_48\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_14\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_14\" for=\"input_14\" aria-hidden=\"false\"> Shift<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_14\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_14\" name=\"q14_shift14\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_14\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_42\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_42\" for=\"input_42\" aria-hidden=\"false\"> Hospital<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_42\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_42\" name=\"q42_hospital\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Hospital\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Barlow Respiratory Hospital\">Barlow Respiratory Hospital<\/option>\n            <option value=\"Encino Hospital Medical Center\">Encino Hospital Medical Center<\/option>\n            <option value=\"Garfield Medical Center\">Garfield Medical Center<\/option>\n            <option value=\"Greater El Monte Community Hospital\">Greater El Monte Community Hospital<\/option>\n            <option value=\"Hollywood Presbyterian Hospital\">Hollywood Presbyterian Hospital<\/option>\n            <option value=\"John F. Kennedy Memorial Hospital\">John F. Kennedy Memorial Hospital<\/option>\n            <option value=\"Kaiser Permanente Moreno Valley\">Kaiser Permanente Moreno Valley<\/option>\n            <option value=\"Kindred Hospital La Mirada\">Kindred Hospital La Mirada<\/option>\n            <option value=\"Kindred Hospital Los Angeles\">Kindred Hospital Los Angeles<\/option>\n            <option value=\"Kindred Hospital Ontario\">Kindred Hospital Ontario<\/option>\n            <option value=\"Kindred Hospital Rancho\">Kindred Hospital Rancho<\/option>\n            <option value=\"Kindred Hospital Riverside\">Kindred Hospital Riverside<\/option>\n            <option value=\"Kindred Hospital South Bay\">Kindred Hospital South Bay<\/option>\n            <option value=\"Los Robles Regional Medical Center\">Los Robles Regional Medical Center<\/option>\n            <option value=\"Monterrey Park Hospital\">Monterrey Park Hospital<\/option>\n            <option value=\"Northridge Hospital Medical Center\">Northridge Hospital Medical Center<\/option>\n            <option value=\"Pacifica Hospital of the Valley\">Pacifica Hospital of the Valley<\/option>\n            <option value=\"Pomona Valley Hospital Medical Center\">Pomona Valley Hospital Medical Center<\/option>\n            <option value=\"Providence St. Joseph Hospital Medical Center\">Providence St. Joseph Hospital Medical Center<\/option>\n            <option value=\"Providence St Joseph Medical Center\">Providence St Joseph Medical Center<\/option>\n            <option value=\"Providence Cedars-Sinai Tarzana Medical Center\">Providence Cedars-Sinai Tarzana Medical Center<\/option>\n            <option value=\"Riverside Community Hospital\">Riverside Community Hospital<\/option>\n            <option value=\"Sierra Vista Behavioral Health Center\">Sierra Vista Behavioral Health Center<\/option>\n            <option value=\"San Dimas Community Hospital\">San Dimas Community Hospital<\/option>\n            <option value=\"Southern California Hospital at Hollywood\">Southern California Hospital at Hollywood<\/option>\n            <option value=\"Southern California Hospital Van Nuys\">Southern California Hospital Van Nuys<\/option>\n            <option value=\"St. John&#x27;s Camarillo Hospital\">St. John&#x27;s Camarillo Hospital<\/option>\n            <option value=\"St. John&#x27;s Regional Medical Center\">St. John&#x27;s Regional Medical Center<\/option>\n            <option value=\"West Hills Hospital and Medical Center\">West Hills Hospital and Medical Center<\/option>\n            <option value=\"Other - please indicate below\">Other - please indicate below<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_52\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_52\" for=\"input_52\" aria-hidden=\"false\"> If you selected &quot;other hospital&quot; please list below <\/label>\n        <div id=\"cid_52\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_52\" name=\"q52_ifYou\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_52\" value=\"\" \/> <\/div>\n      <\/li>\n      <li id=\"cid_15\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-small\">\n          <div class=\"header-text httac htvam\">\n            <h3 id=\"header_15\" class=\"form-header\" data-component=\"header\">Unsafe Assignment Information<\/h3>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_22\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_22\" for=\"input_22\" aria-hidden=\"false\"> Is this an urgent workplace safety issue or something that needs immediate response?<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_22\" name=\"q22_isThis\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Is this an urgent workplace safety issue or something that needs immediate response?\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Yes\">Yes<\/option>\n            <option value=\"No\">No<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required allowTime\" data-type=\"control_datetime\" id=\"id_17\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_17\" for=\"lite_mode_17\" aria-hidden=\"false\"> Date and time of incident<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div data-wrapper-react=\"true\" class=\"extended\">\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_17\" name=\"q17_dateOf[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_17 sublabel_17_month\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"month_17\" id=\"sublabel_17_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_17\" name=\"q17_dateOf[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_17 sublabel_17_day\" \/><span class=\"date-separate\" aria-hidden=\"true\">\u00a0-<\/span><label class=\"form-sub-label\" for=\"day_17\" id=\"sublabel_17_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_17\" name=\"q17_dateOf[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_17 sublabel_17_year\" \/><label class=\"form-sub-label\" for=\"year_17\" id=\"sublabel_17_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_17\" 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_17 sublabel_17_litemode\" \/><img class=\" newDefaultTheme-dateIcon icon-liteMode\" alt=\"Pick a Date\" id=\"input_17_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"Yes\" data-version=\"v2\" \/><label class=\"form-sub-label\" for=\"lite_mode_17\" id=\"sublabel_17_litemode\" style=\"min-height:13px\">Date<\/label><\/span><span class=\"allowTime-container\">\n              <div data-wrapper-react=\"true\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" class=\"time-dropdown form-textbox validate[required, time]\" id=\"input_17_timeInput\" name=\"q17_dateOf[timeInput]\" required=\"\" placeholder=\"HH : MM\" aria-labelledby=\"label_17 sublabel_17_hour\" data-mask=\"HH:MM\" value=\"\" autoComplete=\"off\" data-version=\"v2\" \/><input type=\"hidden\" class=\"form-hidden-time\" id=\"input_17_hourSelect\" name=\"q17_dateOf[hour]\" \/><input type=\"hidden\" class=\"form-hidden-time\" id=\"input_17_minuteSelect\" name=\"q17_dateOf[min]\" \/><label data-seperate-translate=\"true\" class=\"form-sub-label\" for=\"input_17_timeInput\" id=\"sublabel_17_hour\" style=\"min-height:13px\">Hour Minutes<\/label><\/span><\/div>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_49\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_49\" for=\"input_49\" aria-hidden=\"false\"> Patient Room Number <\/label>\n        <div id=\"cid_49\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_49\" name=\"q49_patientRoom\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_49\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_18\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_18\" aria-hidden=\"false\"> Patient Acuity (overall)<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_18\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_18\" data-component=\"radio\"><span class=\"form-radio-item\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_18\" class=\"form-radio validate[required]\" id=\"input_18_0\" name=\"q18_patientAcuity\" value=\"Average\" required=\"\" \/><label id=\"label_input_18_0\" for=\"input_18_0\">Average<\/label><\/span><span class=\"form-radio-item\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_18\" class=\"form-radio validate[required]\" id=\"input_18_1\" name=\"q18_patientAcuity\" value=\"High\" required=\"\" \/><label id=\"label_input_18_1\" for=\"input_18_1\">High<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_47\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_47\" aria-hidden=\"false\"> Describe the acuity using the options below (select all that apply):<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_47\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_47\" data-component=\"checkbox\"><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_0\" name=\"q47_describeThe[]\" value=\"Vents\" required=\"\" \/><label id=\"label_input_47_0\" for=\"input_47_0\">Vents<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_1\" name=\"q47_describeThe[]\" value=\"Drips\" required=\"\" \/><label id=\"label_input_47_1\" for=\"input_47_1\">Drips<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_2\" name=\"q47_describeThe[]\" value=\"Restraints\" required=\"\" \/><label id=\"label_input_47_2\" for=\"input_47_2\">Restraints<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_3\" name=\"q47_describeThe[]\" value=\"Confusion\" required=\"\" \/><label id=\"label_input_47_3\" for=\"input_47_3\">Confusion<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_4\" name=\"q47_describeThe[]\" value=\"1:1\" required=\"\" \/><label id=\"label_input_47_4\" for=\"input_47_4\">1:1<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_5\" name=\"q47_describeThe[]\" value=\"Frequent Neuro Checks\" required=\"\" \/><label id=\"label_input_47_5\" for=\"input_47_5\">Frequent Neuro Checks<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_6\" name=\"q47_describeThe[]\" value=\"Frequent Accu Checks\" required=\"\" \/><label id=\"label_input_47_6\" for=\"input_47_6\">Frequent Accu Checks<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_7\" name=\"q47_describeThe[]\" value=\"Trach patients\" required=\"\" \/><label id=\"label_input_47_7\" for=\"input_47_7\">Trach patients<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_8\" name=\"q47_describeThe[]\" value=\"Violent\/Combative\" required=\"\" \/><label id=\"label_input_47_8\" for=\"input_47_8\">Violent\/Combative<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_9\" name=\"q47_describeThe[]\" value=\"Total Care\" required=\"\" \/><label id=\"label_input_47_9\" for=\"input_47_9\">Total Care<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_47\" class=\"form-checkbox validate[required]\" id=\"input_47_10\" name=\"q47_describeThe[]\" value=\"Higher than normal acuity\" required=\"\" \/><label id=\"label_input_47_10\" for=\"input_47_10\">Higher than normal acuity<\/label><\/span><span class=\"form-checkbox-item formCheckboxOther\"><input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q47_describeThe[other]\" id=\"other_47\" value=\"other\" tabindex=\"0\" aria-label=\"Other (please describe)\" \/><label id=\"label_other_47\" style=\"text-indent:0\" for=\"other_47\">Other (please describe)<\/label><span id=\"other_47_input\" class=\"other-input-container\" style=\"display:none\"><input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q47_describeThe[other]\" data-otherhint=\"Other (please describe)\" size=\"15\" id=\"input_47\" 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 jf-required\" data-type=\"control_checkbox\" id=\"id_20\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_20\" aria-hidden=\"false\"> Concern\/Violation<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_20\" data-component=\"checkbox\"><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_0\" name=\"q20_concernviolation[]\" value=\"Assigned more patients than Title 22 Regulations\" required=\"\" \/><label id=\"label_input_20_0\" for=\"input_20_0\">Assigned more patients than Title 22 Regulations<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_1\" name=\"q20_concernviolation[]\" value=\"Patient acuity not taken into account\" required=\"\" \/><label id=\"label_input_20_1\" for=\"input_20_1\">Patient acuity not taken into account<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_2\" name=\"q20_concernviolation[]\" value=\"In my professional\/critical judgement this assignment is unsafe and places patient(s) at risk\" required=\"\" \/><label id=\"label_input_20_2\" for=\"input_20_2\">In my professional\/critical judgement this assignment is unsafe and places patient(s) at risk<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_3\" name=\"q20_concernviolation[]\" value=\"Reduction in support staff (NAs, Clerks, Transport, EVS, RT, techs)\" required=\"\" \/><label id=\"label_input_20_3\" for=\"input_20_3\">Reduction in support staff (NAs, Clerks, Transport, EVS, RT, techs)<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_4\" name=\"q20_concernviolation[]\" value=\"Use of the buddy system\" required=\"\" \/><label id=\"label_input_20_4\" for=\"input_20_4\">Use of the buddy system<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_5\" name=\"q20_concernviolation[]\" value=\"Unable to take meal or rest breaks\" required=\"\" \/><label id=\"label_input_20_5\" for=\"input_20_5\">Unable to take meal or rest breaks<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_6\" name=\"q20_concernviolation[]\" value=\"Lack of adequate\/appropriate training for assignment - Does not hold appropriate competencies\" required=\"\" \/><label id=\"label_input_20_6\" for=\"input_20_6\">Lack of adequate\/appropriate training for assignment - Does not hold appropriate competencies<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_7\" name=\"q20_concernviolation[]\" value=\"Difficulty observing isolation protocol\" required=\"\" \/><label id=\"label_input_20_7\" for=\"input_20_7\">Difficulty observing isolation protocol<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_8\" name=\"q20_concernviolation[]\" value=\"Difficulty observing HIPAA patient privacy\" required=\"\" \/><label id=\"label_input_20_8\" for=\"input_20_8\">Difficulty observing HIPAA patient privacy<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_20\" class=\"form-checkbox validate[required]\" id=\"input_20_9\" name=\"q20_concernviolation[]\" value=\"Compromised judgement due to fatigue related to the above concerns\" required=\"\" \/><label id=\"label_input_20_9\" for=\"input_20_9\">Compromised judgement due to fatigue related to the above concerns<\/label><\/span><span class=\"form-checkbox-item formCheckboxOther\"><input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q20_concernviolation[other]\" id=\"other_20\" value=\"other\" tabindex=\"0\" aria-label=\"Other\" \/><label id=\"label_other_20\" style=\"text-indent:0\" for=\"other_20\">Other<\/label><span id=\"other_20_input\" class=\"other-input-container\" style=\"display:none\"><input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q20_concernviolation[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_20\" 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 jf-required\" data-type=\"control_dropdown\" id=\"id_21\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_21\" for=\"input_21\" aria-hidden=\"false\"> Because I could be disciplined for refusal of unsafe assignment, I will carry (or have carried) out work to the best of my ability.<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_21\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_21\" name=\"q21_becauseI\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Because I could be disciplined for refusal of unsafe assignment, I will carry (or have carried) out work to the best of my ability.\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Yes\">Yes<\/option>\n            <option value=\"No\">No<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_45\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_45\" aria-hidden=\"false\"> Due to RNs being out of ratio, the following occurred (select all that apply): <span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_45\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_45\" data-component=\"checkbox\"><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_0\" name=\"q45_concernviolation45[]\" value=\"Medications not given\/not given on time\" required=\"\" \/><label id=\"label_input_45_0\" for=\"input_45_0\">Medications not given\/not given on time<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_1\" name=\"q45_concernviolation45[]\" value=\"Treatments not given\/not given on time\" required=\"\" \/><label id=\"label_input_45_1\" for=\"input_45_1\">Treatments not given\/not given on time<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_2\" name=\"q45_concernviolation45[]\" value=\"Total care patients turned less than every 2 hours\" required=\"\" \/><label id=\"label_input_45_2\" for=\"input_45_2\">Total care patients turned less than every 2 hours<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_3\" name=\"q45_concernviolation45[]\" value=\"Poor glycemic control due to food\/medications not being on time\" required=\"\" \/><label id=\"label_input_45_3\" for=\"input_45_3\">Poor glycemic control due to food\/medications not being on time<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_4\" name=\"q45_concernviolation45[]\" value=\"Patient fall\" required=\"\" \/><label id=\"label_input_45_4\" for=\"input_45_4\">Patient fall<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_5\" name=\"q45_concernviolation45[]\" value=\"Patient pressure injury\" required=\"\" \/><label id=\"label_input_45_5\" for=\"input_45_5\">Patient pressure injury<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_6\" name=\"q45_concernviolation45[]\" value=\"Employee workers comp injury\" required=\"\" \/><label id=\"label_input_45_6\" for=\"input_45_6\">Employee workers comp injury<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_7\" name=\"q45_concernviolation45[]\" value=\"Vitals not monitored appropriately\" required=\"\" \/><label id=\"label_input_45_7\" for=\"input_45_7\">Vitals not monitored appropriately<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_8\" name=\"q45_concernviolation45[]\" value=\"Higher use of chemical\/physical restraints\" required=\"\" \/><label id=\"label_input_45_8\" for=\"input_45_8\">Higher use of chemical\/physical restraints<\/label><\/span><span class=\"form-checkbox-item\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_9\" name=\"q45_concernviolation45[]\" value=\"IV medications not titrated appropriately\" required=\"\" \/><label id=\"label_input_45_9\" for=\"input_45_9\">IV medications not titrated appropriately<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_45\" class=\"form-checkbox validate[required]\" id=\"input_45_10\" name=\"q45_concernviolation45[]\" value=\"Unable to take meal or rest breaks\" required=\"\" \/><label id=\"label_input_45_10\" for=\"input_45_10\">Unable to take meal or rest breaks<\/label><\/span><span class=\"form-checkbox-item formCheckboxOther\"><input type=\"checkbox\" class=\"form-checkbox-other form-checkbox validate[required]\" name=\"q45_concernviolation45[other]\" id=\"other_45\" value=\"other\" tabindex=\"0\" aria-label=\"Other\" \/><label id=\"label_other_45\" style=\"text-indent:0\" for=\"other_45\">Other<\/label><span id=\"other_45_input\" class=\"other-input-container\" style=\"display:none\"><input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q45_concernviolation45[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_45\" data-placeholder=\"Please type another option here\" placeholder=\"Please type another option here\" \/><\/span><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_25\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httac htvam\">\n            <h2 id=\"header_25\" class=\"form-header\" data-component=\"header\">Additional details and reporting information<\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textarea\" id=\"id_26\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_26\" for=\"input_26\" aria-hidden=\"false\"> Describe, in detail, the impact on patient(s). Include any other event(s) that adversely affected patients. Was there potential or actual negative patient outcome?<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_26\" class=\"form-input-wide jf-required\" data-layout=\"full\"> <textarea id=\"input_26\" class=\"form-textarea validate[required]\" name=\"q26_describeIn\" style=\"width:648px;height:163px\" data-component=\"textarea\" required=\"\" aria-labelledby=\"label_26\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_27\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_27\" for=\"input_27\" aria-hidden=\"false\"> Was your supervisor (House Supervisor, Manager, Director) notified about your unsafe assignment in writing?<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_27\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_27\" name=\"q27_wasYour\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Was your  supervisor (House Supervisor, Manager, Director) notified about your unsafe assignment in writing?\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Yes\">Yes<\/option>\n            <option value=\"No\">No<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_28\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_28\" for=\"input_28\" aria-hidden=\"false\"> Name of supervisor notified: <\/label>\n        <div id=\"cid_28\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_28\" name=\"q28_nameOf\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_28\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_29\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_29\" for=\"input_29\" aria-hidden=\"false\"> Method of notification (text, email, fax, or other method in writing - please specify) <\/label>\n        <div id=\"cid_29\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_29\" name=\"q29_methodOf\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_29\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_30\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_30\" for=\"input_30\" aria-hidden=\"false\"> Was an incident report filled out?<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_30\" name=\"q30_wasAn\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Was an incident report filled out?\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Yes\">Yes<\/option>\n            <option value=\"No\">No<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_divider\" id=\"id_35\">\n        <div id=\"cid_35\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"divider\" data-component=\"divider\" style=\"border-bottom-width:1px;border-bottom-style:solid;border-color:#ecedf3;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px\"><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_dropdown\" id=\"id_43\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_43\" for=\"input_43\" aria-hidden=\"false\"> Select &quot;Yes&quot; if you intend to send a copy of your signed form to your supervisor. (You will automatically receive a confirmation email with your responses.) <\/label>\n        <div id=\"cid_43\" class=\"form-input-wide always-hidden\" data-layout=\"half\"> <select class=\"form-dropdown\" id=\"input_43\" name=\"q43_selectyes\" style=\"width:310px\" data-component=\"dropdown\" aria-label=\"Select &quot;Yes&quot; if you intend to send a copy of your signed form to your supervisor. (You will automatically receive a confirmation email with your responses.)\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Yes\">Yes<\/option>\n            <option value=\"No\">No<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_51\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_51\" for=\"input_51\" aria-hidden=\"false\"> Do you give SEIU 121RN permission to forward this report to the California Department of Public Health (CDPH)?<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_51\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_51\" name=\"q51_doYou\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Do you give SEIU 121RN permission to forward this report to the California Department of Public Health (CDPH)?\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"Yes\">Yes<\/option>\n            <option value=\"No\">No<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_44\">\n        <div id=\"cid_44\" class=\"form-input-wide\" data-layout=\"full\">\n          <div id=\"text_44\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p>As a patient advocate, in accordance with the California Nurse Practice Act, I will send this completed form to my supervisor to notify hospital administrators, as well as to any other relevant parties. I submit that, in my professional judgement, today's assignment and\/or other workplace conditions are not in accordance with California's Title 22 regulations and raise patient safety concerns.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_signature\" id=\"id_33\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_33\" for=\"input_33\" aria-hidden=\"false\"> Signature <\/label>\n        <div id=\"cid_33\" class=\"form-input-wide\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div id=\"signature_pad_33\" 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_33\" data-width=\"310\" data-height=\"114\" data-id=\"33\" data-required=\"false\" class=\"pad \" aria-labelledby=\"label_33\"><\/div><input type=\"hidden\" name=\"q33_signature\" class=\"output4\" id=\"input_33\" \/>\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 = \"old_footer\";\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=\"222687067615059\" \/>\n  <script type=\"text\/javascript\">\n    var all_spc = document.querySelectorAll(\"form[id='222687067615059'] .si\" + \"mple\" + \"_spc\");\n    for (var i = 0; i < all_spc.length; i++)\n    {\n      all_spc[i].value = \"222687067615059-222687067615059\";\n    }\n  <\/script>\n<\/form><\/body>\n<\/html><script type=\"text\/javascript\">JotForm.isNewSACL=true;<\/script>","Patient Safety Reporting Form (ADO) ",Array);var permittedDomains=[];try{var renderURLDomain=new URL("https://form.jotform.com/222687067615059").hostname;permittedDomains=[renderURLDomain];}catch(e){permittedDomains=['jotform.com','jotform.pro'];}
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