{"id":174,"date":"2020-12-31T19:23:53","date_gmt":"2020-12-31T19:23:53","guid":{"rendered":"https:\/\/wcc-tech.ca\/home\/?page_id=174"},"modified":"2021-01-10T21:57:06","modified_gmt":"2021-01-10T21:57:06","slug":"covid-screening","status":"publish","type":"page","link":"https:\/\/wcc-tech.ca\/home\/covid-screening\/","title":{"rendered":"COVID Screening"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221;][et_pb_fullwidth_menu menu_id=&#8221;4&#8243; active_link_color=&#8221;#f7f9ff&#8221; logo=&#8221;https:\/\/wcc-tech.ca\/home\/wp-content\/uploads\/2020\/12\/WCCT.png&#8221; _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221; menu_text_color=&#8221;#ffffff&#8221; background_color=&#8221;#201c44&#8243; text_orientation=&#8221;right&#8221; background_layout=&#8221;dark&#8221; menu_font_tablet=&#8221;&#8221; menu_font_phone=&#8221;&#8221; menu_font_last_edited=&#8221;on|desktop&#8221; box_shadow_style=&#8221;preset2&#8243;][\/et_pb_fullwidth_menu][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221; background_image=&#8221;https:\/\/wcc-tech.ca\/home\/wp-content\/uploads\/2020\/12\/communication-tower-design-02.png&#8221; custom_padding=&#8221;54px||54px||false|&#8221;][et_pb_row _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#201c44&#8243; custom_padding=&#8221;|20px||20px|false|true&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221;][et_pb_text _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221; text_text_color=&#8221;#ffffff&#8221; background_image=&#8221;https:\/\/wcc-tech.ca\/home\/wp-content\/uploads\/2021\/01\/corona-virus-03.jpg&#8221; min_height=&#8221;98px&#8221; custom_margin=&#8221;||||false|false&#8221; custom_padding=&#8221;40px|20px|40px|20px|true|true&#8221; text_text_shadow_style=&#8221;preset2&#8243; text_text_shadow_color=&#8221;#201c44&#8243; header_text_shadow_style=&#8221;preset2&#8243; header_text_shadow_color=&#8221;#201c44&#8243;]<\/p>\n<h1 style=\"text-align: center;\"><span style=\"color: #ffffff;\"><strong>COVID-19 Screening Form<\/strong><\/span><\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#d7deed&#8221; box_shadow_style=&#8221;preset6&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.6.0&#8243; _module_preset=&#8221;default&#8221;][et_pb_text _builder_version=&#8221;4.7.7&#8243; _module_preset=&#8221;default&#8221; min_height=&#8221;190px&#8221; custom_padding=&#8221;|20px||20px|false|true&#8221;]<\/p>\n<div id=\"quform-88ed29\" class=\"quform quform-1 quform-theme-light quform-support-page-caching\"><form id=\"quform-form-88ed29\" class=\"quform-form quform-form-1\" action=\"\/home\/wp-json\/wp\/v2\/pages\/174#quform-88ed29\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:1,&quot;uniqueId&quot;:&quot;88ed29&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:{&quot;91&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;80&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Yes&quot;}]}},&quot;dependents&quot;:{&quot;80&quot;:[91]},&quot;elementIds&quot;:[91],&quot;dependentElementIds&quot;:[&quot;80&quot;],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:false,&quot;pages&quot;:[1],&quot;pageProgressType&quot;:&quot;numbers&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-1\"><input type=\"hidden\" name=\"quform_form_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"88ed29\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/wcc-tech.ca\/home\/wp-json\/wp\/v2\/pages\/174\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"Eia2Yq7SiZOp26BlJdNeQ5kiJW1qy5NARCWJpknL\" \/><div class=\"quform-form-title-description\"><div class=\"quform-form-title\"><div style=\"text-align:center\">All Items must be filled out before this form can be submitted.<br><br><\/div><\/div><\/div><div class=\"quform-elements quform-elements-1 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-element quform-element-page quform-page-1 quform-page-1_1 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-1_6 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Customer Contact Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_8 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_9\"><div class=\"quform-element quform-element-text quform-element-1_41 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_41\"><label class=\"quform-label-text\" for=\"quform_1_41_88ed29\">First Name<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_41\"><div class=\"quform-input quform-input-text quform-input-1_41 quform-cf\"><input type=\"text\" id=\"quform_1_41_88ed29\" name=\"quform_1_41\" class=\"quform-field quform-field-text quform-field-1_41\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_40\"><div class=\"quform-element quform-element-text quform-element-1_42 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_42\"><label class=\"quform-label-text\" for=\"quform_1_42_88ed29\">Last Name<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_42\"><div class=\"quform-input quform-input-text quform-input-1_42 quform-cf\"><input type=\"text\" id=\"quform_1_42_88ed29\" name=\"quform_1_42\" class=\"quform-field quform-field-text quform-field-1_42\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_14 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_15\"><div class=\"quform-element quform-element-text quform-element-1_20 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_20\"><label class=\"quform-label-text\" for=\"quform_1_20_88ed29\">Phone Number<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_20\"><div class=\"quform-input quform-input-text quform-input-1_20 quform-cf\"><input type=\"text\" id=\"quform_1_20_88ed29\" name=\"quform_1_20\" class=\"quform-field quform-field-text quform-field-1_20\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_16\"><div class=\"quform-element quform-element-email quform-element-1_18 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_18\"><label class=\"quform-label-text\" for=\"quform_1_18_88ed29\">Email address<\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-1_18\"><div class=\"quform-input quform-input-email quform-input-1_18 quform-cf\"><input type=\"email\" id=\"quform_1_18_88ed29\" name=\"quform_1_18\" class=\"quform-field quform-field-email quform-field-1_18\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_116 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_117\"><div class=\"quform-element quform-element-date quform-element-1_121 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_121\"><label class=\"quform-label-text\" for=\"quform_1_121_88ed29\">Service Call Date<\/label><\/div><div class=\"quform-inner quform-inner-date quform-inner-1_121\"><div class=\"quform-input quform-input-date quform-input-1_121 quform-cf quform-has-field-icon-right\"><input type=\"text\" id=\"quform_1_121_88ed29\" name=\"quform_1_121\" class=\"quform-field quform-field-date quform-field-1_121\" placeholder=\"YYYY-MM-DD\" data-options=\"{&quot;format&quot;:&quot;&quot;,&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;start&quot;:&quot;month&quot;,&quot;depth&quot;:&quot;month&quot;,&quot;showFooter&quot;:false,&quot;locale&quot;:&quot;en-US&quot;,&quot;placeholder&quot;:&quot;&quot;,&quot;autoOpen&quot;:true,&quot;identifier&quot;:&quot;1_121&quot;}\" \/><span class=\"quform-field-icon quform-field-icon-right\"><i class=\"qicon-calendar\"><\/i><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_7 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Travel Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_21 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_22\"><div class=\"quform-element quform-element-radio quform-element-1_62 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_62\"><label class=\"quform-label-text\" id=\"quform_1_62_88ed29_label\">Did you or any member of your household travel outside of Ontario in the past 14 days?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_62\"><div class=\"quform-input quform-input-radio quform-input-1_62 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_62_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_62\" id=\"quform_1_62_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_62 quform-field-1_62_1\" value=\"Yes\" \/><label for=\"quform_1_62_88ed29_1\" class=\"quform-option-label quform-option-label-1_62_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_62\" id=\"quform_1_62_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_62 quform-field-1_62_2\" value=\"No\" \/><label for=\"quform_1_62_88ed29_2\" class=\"quform-option-label quform-option-label-1_62_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_23\"><div class=\"quform-element quform-element-radio quform-element-1_64 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_64\"><label class=\"quform-label-text\" id=\"quform_1_64_88ed29_label\">Did you or any member of your household have a confirmed case of COVID-19, or contact with anyone that has?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_64\"><div class=\"quform-input quform-input-radio quform-input-1_64 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_64_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_64\" id=\"quform_1_64_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_64 quform-field-1_64_1\" value=\"Yes\" \/><label for=\"quform_1_64_88ed29_1\" class=\"quform-option-label quform-option-label-1_64_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_64\" id=\"quform_1_64_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_64 quform-field-1_64_2\" value=\"No\" \/><label for=\"quform_1_64_88ed29_2\" class=\"quform-option-label quform-option-label-1_64_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_52 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Symptom Information - Are you or any member of your household experiencing any of the following symptoms?<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_53 quform-3-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_54\"><div class=\"quform-element quform-element-radio quform-element-1_65 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_65\"><label class=\"quform-label-text\" id=\"quform_1_65_88ed29_label\">Fever<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_65\"><div class=\"quform-input quform-input-radio quform-input-1_65 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_65_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_65\" id=\"quform_1_65_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_65 quform-field-1_65_1\" value=\"Yes\" \/><label for=\"quform_1_65_88ed29_1\" class=\"quform-option-label quform-option-label-1_65_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_65\" id=\"quform_1_65_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_65 quform-field-1_65_2\" value=\"No\" \/><label for=\"quform_1_65_88ed29_2\" class=\"quform-option-label quform-option-label-1_65_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_69 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_69\"><label class=\"quform-label-text\" id=\"quform_1_69_88ed29_label\">Shortness of breath<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_69\"><div class=\"quform-input quform-input-radio quform-input-1_69 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_69_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_69\" id=\"quform_1_69_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_69 quform-field-1_69_1\" value=\"Yes\" \/><label for=\"quform_1_69_88ed29_1\" class=\"quform-option-label quform-option-label-1_69_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_69\" id=\"quform_1_69_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_69 quform-field-1_69_2\" value=\"No\" \/><label for=\"quform_1_69_88ed29_2\" class=\"quform-option-label quform-option-label-1_69_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_72 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_72\"><label class=\"quform-label-text\" id=\"quform_1_72_88ed29_label\">Difficulty swallowing<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_72\"><div class=\"quform-input quform-input-radio quform-input-1_72 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_72_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_72\" id=\"quform_1_72_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_72 quform-field-1_72_1\" value=\"Yes\" \/><label for=\"quform_1_72_88ed29_1\" class=\"quform-option-label quform-option-label-1_72_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_72\" id=\"quform_1_72_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_72 quform-field-1_72_2\" value=\"No\" \/><label for=\"quform_1_72_88ed29_2\" class=\"quform-option-label quform-option-label-1_72_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_75 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_75\"><label class=\"quform-label-text\" id=\"quform_1_75_88ed29_label\">Headaches<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_75\"><div class=\"quform-input quform-input-radio quform-input-1_75 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_75_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_75\" id=\"quform_1_75_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_75 quform-field-1_75_1\" value=\"Yes\" \/><label for=\"quform_1_75_88ed29_1\" class=\"quform-option-label quform-option-label-1_75_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_75\" id=\"quform_1_75_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_75 quform-field-1_75_2\" value=\"No\" \/><label for=\"quform_1_75_88ed29_2\" class=\"quform-option-label quform-option-label-1_75_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_78 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_78\"><label class=\"quform-label-text\" id=\"quform_1_78_88ed29_label\">Pink eye<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_78\"><div class=\"quform-input quform-input-radio quform-input-1_78 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_78_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_78\" id=\"quform_1_78_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_78 quform-field-1_78_1\" value=\"Yes\" \/><label for=\"quform_1_78_88ed29_1\" class=\"quform-option-label quform-option-label-1_78_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_78\" id=\"quform_1_78_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_78 quform-field-1_78_2\" value=\"No\" \/><label for=\"quform_1_78_88ed29_2\" class=\"quform-option-label quform-option-label-1_78_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_56\"><div class=\"quform-element quform-element-radio quform-element-1_66 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_66\"><label class=\"quform-label-text\" id=\"quform_1_66_88ed29_label\">New onset of cough<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_66\"><div class=\"quform-input quform-input-radio quform-input-1_66 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_66_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_66\" id=\"quform_1_66_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_66 quform-field-1_66_1\" value=\"Yes\" \/><label for=\"quform_1_66_88ed29_1\" class=\"quform-option-label quform-option-label-1_66_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_66\" id=\"quform_1_66_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_66 quform-field-1_66_2\" value=\"No\" \/><label for=\"quform_1_66_88ed29_2\" class=\"quform-option-label quform-option-label-1_66_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_73 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_73\"><label class=\"quform-label-text\" id=\"quform_1_73_88ed29_label\">Difficulty breathing<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_73\"><div class=\"quform-input quform-input-radio quform-input-1_73 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_73_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_73\" id=\"quform_1_73_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_73 quform-field-1_73_1\" value=\"Yes\" \/><label for=\"quform_1_73_88ed29_1\" class=\"quform-option-label quform-option-label-1_73_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_73\" id=\"quform_1_73_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_73 quform-field-1_73_2\" value=\"No\" \/><label for=\"quform_1_73_88ed29_2\" class=\"quform-option-label quform-option-label-1_73_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_70 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_70\"><label class=\"quform-label-text\" id=\"quform_1_70_88ed29_label\">Decrease of loss of sense of taste or smell<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_70\"><div class=\"quform-input quform-input-radio quform-input-1_70 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_70_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_70\" id=\"quform_1_70_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_70 quform-field-1_70_1\" value=\"Yes\" \/><label for=\"quform_1_70_88ed29_1\" class=\"quform-option-label quform-option-label-1_70_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_70\" id=\"quform_1_70_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_70 quform-field-1_70_2\" value=\"No\" \/><label for=\"quform_1_70_88ed29_2\" class=\"quform-option-label quform-option-label-1_70_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_76 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_76\"><label class=\"quform-label-text\" id=\"quform_1_76_88ed29_label\">Unexplained fatigue\/malaise\/muscle aches<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_76\"><div class=\"quform-input quform-input-radio quform-input-1_76 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_76_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_76\" id=\"quform_1_76_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_76 quform-field-1_76_1\" value=\"Yes\" \/><label for=\"quform_1_76_88ed29_1\" class=\"quform-option-label quform-option-label-1_76_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_76\" id=\"quform_1_76_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_76 quform-field-1_76_2\" value=\"No\" \/><label for=\"quform_1_76_88ed29_2\" class=\"quform-option-label quform-option-label-1_76_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_67\"><div class=\"quform-element quform-element-radio quform-element-1_68 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_68\"><label class=\"quform-label-text\" id=\"quform_1_68_88ed29_label\">Worsening chronic cough<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_68\"><div class=\"quform-input quform-input-radio quform-input-1_68 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_68_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_68\" id=\"quform_1_68_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_68 quform-field-1_68_1\" value=\"Yes\" \/><label for=\"quform_1_68_88ed29_1\" class=\"quform-option-label quform-option-label-1_68_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_68\" id=\"quform_1_68_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_68 quform-field-1_68_2\" value=\"No\" \/><label for=\"quform_1_68_88ed29_2\" class=\"quform-option-label quform-option-label-1_68_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_71 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_71\"><label class=\"quform-label-text\" id=\"quform_1_71_88ed29_label\">Sore throat<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_71\"><div class=\"quform-input quform-input-radio quform-input-1_71 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_71_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_71\" id=\"quform_1_71_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_71 quform-field-1_71_1\" value=\"Yes\" \/><label for=\"quform_1_71_88ed29_1\" class=\"quform-option-label quform-option-label-1_71_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_71\" id=\"quform_1_71_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_71 quform-field-1_71_2\" value=\"No\" \/><label for=\"quform_1_71_88ed29_2\" class=\"quform-option-label quform-option-label-1_71_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_74 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_74\"><label class=\"quform-label-text\" id=\"quform_1_74_88ed29_label\">Chills<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_74\"><div class=\"quform-input quform-input-radio quform-input-1_74 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_74_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_74\" id=\"quform_1_74_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_74 quform-field-1_74_1\" value=\"Yes\" \/><label for=\"quform_1_74_88ed29_1\" class=\"quform-option-label quform-option-label-1_74_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_74\" id=\"quform_1_74_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_74 quform-field-1_74_2\" value=\"No\" \/><label for=\"quform_1_74_88ed29_2\" class=\"quform-option-label quform-option-label-1_74_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_77 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_77\"><label class=\"quform-label-text\" id=\"quform_1_77_88ed29_label\">Nausea\/vomiting, diarrhea, abdominal pain<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_77\"><div class=\"quform-input quform-input-radio quform-input-1_77 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_77_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_77\" id=\"quform_1_77_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_77 quform-field-1_77_1\" value=\"Yes\" \/><label for=\"quform_1_77_88ed29_1\" class=\"quform-option-label quform-option-label-1_77_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_77\" id=\"quform_1_77_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_77 quform-field-1_77_2\" value=\"No\" \/><label for=\"quform_1_77_88ed29_2\" class=\"quform-option-label quform-option-label-1_77_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_79 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_79\"><label class=\"quform-label-text\" id=\"quform_1_79_88ed29_label\">Runny nose or nasal congestion without known cause<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_79\"><div class=\"quform-input quform-input-radio quform-input-1_79 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_79_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_79\" id=\"quform_1_79_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_79 quform-field-1_79_1\" value=\"Yes\" \/><label for=\"quform_1_79_88ed29_1\" class=\"quform-option-label quform-option-label-1_79_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_79\" id=\"quform_1_79_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_79 quform-field-1_79_2\" value=\"No\" \/><label for=\"quform_1_79_88ed29_2\" class=\"quform-option-label quform-option-label-1_79_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_45 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Age Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_46 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_47\"><div class=\"quform-element quform-element-radio quform-element-1_80 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_80\"><label class=\"quform-label-text\" id=\"quform_1_80_88ed29_label\">Are you or any member for your household 70 years old or older?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_80\"><div class=\"quform-input quform-input-radio quform-input-1_80 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_80_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_80\" id=\"quform_1_80_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_80 quform-field-1_80_1\" value=\"Yes\" \/><label for=\"quform_1_80_88ed29_1\" class=\"quform-option-label quform-option-label-1_80_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_80\" id=\"quform_1_80_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_80 quform-field-1_80_2\" value=\"No\" \/><label for=\"quform_1_80_88ed29_2\" class=\"quform-option-label quform-option-label-1_80_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_91 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Is any member of your household older than 70 experiencing any of the following symptoms?<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_95 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_96\"><div class=\"quform-element quform-element-radio quform-element-1_97 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_97\"><label class=\"quform-label-text\" id=\"quform_1_97_88ed29_label\">Delirium<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_97\"><div class=\"quform-input quform-input-radio quform-input-1_97 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_97_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_97\" id=\"quform_1_97_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_97 quform-field-1_97_1\" value=\"Yes\" \/><label for=\"quform_1_97_88ed29_1\" class=\"quform-option-label quform-option-label-1_97_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_97\" id=\"quform_1_97_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_97 quform-field-1_97_2\" value=\"No\" \/><label for=\"quform_1_97_88ed29_2\" class=\"quform-option-label quform-option-label-1_97_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_98 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_98\"><label class=\"quform-label-text\" id=\"quform_1_98_88ed29_label\">Acute functional decline<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_98\"><div class=\"quform-input quform-input-radio quform-input-1_98 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_98_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_98\" id=\"quform_1_98_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_98 quform-field-1_98_1\" value=\"Yes\" \/><label for=\"quform_1_98_88ed29_1\" class=\"quform-option-label quform-option-label-1_98_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_98\" id=\"quform_1_98_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_98 quform-field-1_98_2\" value=\"No\" \/><label for=\"quform_1_98_88ed29_2\" class=\"quform-option-label quform-option-label-1_98_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_99\"><div class=\"quform-element quform-element-radio quform-element-1_100 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_100\"><label class=\"quform-label-text\" id=\"quform_1_100_88ed29_label\">Unexplained or increased number of falls<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_100\"><div class=\"quform-input quform-input-radio quform-input-1_100 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_100_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_100\" id=\"quform_1_100_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_100 quform-field-1_100_1\" value=\"Yes\" \/><label for=\"quform_1_100_88ed29_1\" class=\"quform-option-label quform-option-label-1_100_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_100\" id=\"quform_1_100_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_100 quform-field-1_100_2\" value=\"No\" \/><label for=\"quform_1_100_88ed29_2\" class=\"quform-option-label quform-option-label-1_100_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_101 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_101\"><label class=\"quform-label-text\" id=\"quform_1_101_88ed29_label\">Worsening of chronic conditions<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_101\"><div class=\"quform-input quform-input-radio quform-input-1_101 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_101_88ed29_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_101\" id=\"quform_1_101_88ed29_1\" class=\"quform-field quform-field-radio quform-field-1_101 quform-field-1_101_1\" value=\"Yes\" \/><label for=\"quform_1_101_88ed29_1\" class=\"quform-option-label quform-option-label-1_101_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_101\" id=\"quform_1_101_88ed29_2\" class=\"quform-field quform-field-radio quform-field-1_101 quform-field-1_101_2\" value=\"No\" \/><label for=\"quform_1_101_88ed29_2\" class=\"quform-option-label quform-option-label-1_101_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_36 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Submit Report<\/h4><p class=\"quform-group-description\">By submitting this form you are confirming that to the best of your knowledge all of the information provided is correct.\n\nThank you for helping us protect one another from COVID-19.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_37 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_38\"><div class=\"quform-element quform-element-recaptcha quform-element-1_35 quform-cf quform-element-required quform-recaptcha-no-size\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-recaptcha quform-inner-1_35\"><div class=\"quform-input quform-input-recaptcha quform-input-1_35 quform-cf\"><div class=\"quform-recaptcha\" data-config=\"{&quot;sitekey&quot;:&quot;6Lf5NiYaAAAAAPLfaCxmaml5vFmEnzhrqj97CvwH&quot;,&quot;_version&quot;:&quot;v3&quot;,&quot;size&quot;:&quot;invisible&quot;,&quot;type&quot;:&quot;image&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;badge&quot;:&quot;bottomright&quot;}\"><\/div><noscript>Please enable JavaScript to submit this form.<\/noscript><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_2 quform-cf quform-button-style-theme\"><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-1_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Submit<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>COVID-19 Screening Form<div id=\"quform-a0eb20\" class=\"quform quform-1 quform-theme-light quform-support-page-caching\"><form id=\"quform-form-a0eb20\" class=\"quform-form quform-form-1\" action=\"\/home\/wp-json\/wp\/v2\/pages\/174#quform-a0eb20\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:1,&quot;uniqueId&quot;:&quot;a0eb20&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:{&quot;91&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;80&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Yes&quot;}]}},&quot;dependents&quot;:{&quot;80&quot;:[91]},&quot;elementIds&quot;:[91],&quot;dependentElementIds&quot;:[&quot;80&quot;],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:false,&quot;pages&quot;:[1],&quot;pageProgressType&quot;:&quot;numbers&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-1\"><input type=\"hidden\" name=\"quform_form_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"a0eb20\" \/><input type=\"hidden\" name=\"quform_count\" value=\"2\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/wcc-tech.ca\/home\/wp-json\/wp\/v2\/pages\/174\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"Eia2Yq7SiZOp26BlJdNeQ5kiJW1qy5NARCWJpknL\" \/><div class=\"quform-form-title-description\"><div class=\"quform-form-title\"><div style=\"text-align:center\">All Items must be filled out before this form can be submitted.<br><br><\/div><\/div><\/div><div class=\"quform-elements quform-elements-1 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-element quform-element-page quform-page-1 quform-page-1_1 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-1_6 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Customer Contact Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_8 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_9\"><div class=\"quform-element quform-element-text quform-element-1_41 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_41\"><label class=\"quform-label-text\" for=\"quform_1_41_a0eb20\">First Name<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_41\"><div class=\"quform-input quform-input-text quform-input-1_41 quform-cf\"><input type=\"text\" id=\"quform_1_41_a0eb20\" name=\"quform_1_41\" class=\"quform-field quform-field-text quform-field-1_41\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_40\"><div class=\"quform-element quform-element-text quform-element-1_42 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_42\"><label class=\"quform-label-text\" for=\"quform_1_42_a0eb20\">Last Name<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_42\"><div class=\"quform-input quform-input-text quform-input-1_42 quform-cf\"><input type=\"text\" id=\"quform_1_42_a0eb20\" name=\"quform_1_42\" class=\"quform-field quform-field-text quform-field-1_42\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_14 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_15\"><div class=\"quform-element quform-element-text quform-element-1_20 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_20\"><label class=\"quform-label-text\" for=\"quform_1_20_a0eb20\">Phone Number<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_20\"><div class=\"quform-input quform-input-text quform-input-1_20 quform-cf\"><input type=\"text\" id=\"quform_1_20_a0eb20\" name=\"quform_1_20\" class=\"quform-field quform-field-text quform-field-1_20\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_16\"><div class=\"quform-element quform-element-email quform-element-1_18 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_18\"><label class=\"quform-label-text\" for=\"quform_1_18_a0eb20\">Email address<\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-1_18\"><div class=\"quform-input quform-input-email quform-input-1_18 quform-cf\"><input type=\"email\" id=\"quform_1_18_a0eb20\" name=\"quform_1_18\" class=\"quform-field quform-field-email quform-field-1_18\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_116 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_117\"><div class=\"quform-element quform-element-date quform-element-1_121 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_121\"><label class=\"quform-label-text\" for=\"quform_1_121_a0eb20\">Service Call Date<\/label><\/div><div class=\"quform-inner quform-inner-date quform-inner-1_121\"><div class=\"quform-input quform-input-date quform-input-1_121 quform-cf quform-has-field-icon-right\"><input type=\"text\" id=\"quform_1_121_a0eb20\" name=\"quform_1_121\" class=\"quform-field quform-field-date quform-field-1_121\" placeholder=\"YYYY-MM-DD\" data-options=\"{&quot;format&quot;:&quot;&quot;,&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;start&quot;:&quot;month&quot;,&quot;depth&quot;:&quot;month&quot;,&quot;showFooter&quot;:false,&quot;locale&quot;:&quot;en-US&quot;,&quot;placeholder&quot;:&quot;&quot;,&quot;autoOpen&quot;:true,&quot;identifier&quot;:&quot;1_121&quot;}\" \/><span class=\"quform-field-icon quform-field-icon-right\"><i class=\"qicon-calendar\"><\/i><\/span><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_7 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Travel Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_21 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_22\"><div class=\"quform-element quform-element-radio quform-element-1_62 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_62\"><label class=\"quform-label-text\" id=\"quform_1_62_a0eb20_label\">Did you or any member of your household travel outside of Ontario in the past 14 days?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_62\"><div class=\"quform-input quform-input-radio quform-input-1_62 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_62_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_62\" id=\"quform_1_62_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_62 quform-field-1_62_1\" value=\"Yes\" \/><label for=\"quform_1_62_a0eb20_1\" class=\"quform-option-label quform-option-label-1_62_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_62\" id=\"quform_1_62_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_62 quform-field-1_62_2\" value=\"No\" \/><label for=\"quform_1_62_a0eb20_2\" class=\"quform-option-label quform-option-label-1_62_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_23\"><div class=\"quform-element quform-element-radio quform-element-1_64 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_64\"><label class=\"quform-label-text\" id=\"quform_1_64_a0eb20_label\">Did you or any member of your household have a confirmed case of COVID-19, or contact with anyone that has?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_64\"><div class=\"quform-input quform-input-radio quform-input-1_64 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_64_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_64\" id=\"quform_1_64_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_64 quform-field-1_64_1\" value=\"Yes\" \/><label for=\"quform_1_64_a0eb20_1\" class=\"quform-option-label quform-option-label-1_64_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_64\" id=\"quform_1_64_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_64 quform-field-1_64_2\" value=\"No\" \/><label for=\"quform_1_64_a0eb20_2\" class=\"quform-option-label quform-option-label-1_64_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_52 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Symptom Information - Are you or any member of your household experiencing any of the following symptoms?<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_53 quform-3-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_54\"><div class=\"quform-element quform-element-radio quform-element-1_65 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_65\"><label class=\"quform-label-text\" id=\"quform_1_65_a0eb20_label\">Fever<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_65\"><div class=\"quform-input quform-input-radio quform-input-1_65 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_65_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_65\" id=\"quform_1_65_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_65 quform-field-1_65_1\" value=\"Yes\" \/><label for=\"quform_1_65_a0eb20_1\" class=\"quform-option-label quform-option-label-1_65_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_65\" id=\"quform_1_65_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_65 quform-field-1_65_2\" value=\"No\" \/><label for=\"quform_1_65_a0eb20_2\" class=\"quform-option-label quform-option-label-1_65_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_69 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_69\"><label class=\"quform-label-text\" id=\"quform_1_69_a0eb20_label\">Shortness of breath<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_69\"><div class=\"quform-input quform-input-radio quform-input-1_69 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_69_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_69\" id=\"quform_1_69_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_69 quform-field-1_69_1\" value=\"Yes\" \/><label for=\"quform_1_69_a0eb20_1\" class=\"quform-option-label quform-option-label-1_69_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_69\" id=\"quform_1_69_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_69 quform-field-1_69_2\" value=\"No\" \/><label for=\"quform_1_69_a0eb20_2\" class=\"quform-option-label quform-option-label-1_69_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_72 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_72\"><label class=\"quform-label-text\" id=\"quform_1_72_a0eb20_label\">Difficulty swallowing<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_72\"><div class=\"quform-input quform-input-radio quform-input-1_72 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_72_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_72\" id=\"quform_1_72_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_72 quform-field-1_72_1\" value=\"Yes\" \/><label for=\"quform_1_72_a0eb20_1\" class=\"quform-option-label quform-option-label-1_72_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_72\" id=\"quform_1_72_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_72 quform-field-1_72_2\" value=\"No\" \/><label for=\"quform_1_72_a0eb20_2\" class=\"quform-option-label quform-option-label-1_72_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_75 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_75\"><label class=\"quform-label-text\" id=\"quform_1_75_a0eb20_label\">Headaches<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_75\"><div class=\"quform-input quform-input-radio quform-input-1_75 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_75_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_75\" id=\"quform_1_75_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_75 quform-field-1_75_1\" value=\"Yes\" \/><label for=\"quform_1_75_a0eb20_1\" class=\"quform-option-label quform-option-label-1_75_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_75\" id=\"quform_1_75_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_75 quform-field-1_75_2\" value=\"No\" \/><label for=\"quform_1_75_a0eb20_2\" class=\"quform-option-label quform-option-label-1_75_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_78 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_78\"><label class=\"quform-label-text\" id=\"quform_1_78_a0eb20_label\">Pink eye<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_78\"><div class=\"quform-input quform-input-radio quform-input-1_78 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_78_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_78\" id=\"quform_1_78_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_78 quform-field-1_78_1\" value=\"Yes\" \/><label for=\"quform_1_78_a0eb20_1\" class=\"quform-option-label quform-option-label-1_78_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_78\" id=\"quform_1_78_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_78 quform-field-1_78_2\" value=\"No\" \/><label for=\"quform_1_78_a0eb20_2\" class=\"quform-option-label quform-option-label-1_78_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_56\"><div class=\"quform-element quform-element-radio quform-element-1_66 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_66\"><label class=\"quform-label-text\" id=\"quform_1_66_a0eb20_label\">New onset of cough<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_66\"><div class=\"quform-input quform-input-radio quform-input-1_66 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_66_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_66\" id=\"quform_1_66_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_66 quform-field-1_66_1\" value=\"Yes\" \/><label for=\"quform_1_66_a0eb20_1\" class=\"quform-option-label quform-option-label-1_66_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_66\" id=\"quform_1_66_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_66 quform-field-1_66_2\" value=\"No\" \/><label for=\"quform_1_66_a0eb20_2\" class=\"quform-option-label quform-option-label-1_66_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_73 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_73\"><label class=\"quform-label-text\" id=\"quform_1_73_a0eb20_label\">Difficulty breathing<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_73\"><div class=\"quform-input quform-input-radio quform-input-1_73 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_73_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_73\" id=\"quform_1_73_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_73 quform-field-1_73_1\" value=\"Yes\" \/><label for=\"quform_1_73_a0eb20_1\" class=\"quform-option-label quform-option-label-1_73_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_73\" id=\"quform_1_73_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_73 quform-field-1_73_2\" value=\"No\" \/><label for=\"quform_1_73_a0eb20_2\" class=\"quform-option-label quform-option-label-1_73_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_70 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_70\"><label class=\"quform-label-text\" id=\"quform_1_70_a0eb20_label\">Decrease of loss of sense of taste or smell<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_70\"><div class=\"quform-input quform-input-radio quform-input-1_70 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_70_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_70\" id=\"quform_1_70_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_70 quform-field-1_70_1\" value=\"Yes\" \/><label for=\"quform_1_70_a0eb20_1\" class=\"quform-option-label quform-option-label-1_70_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_70\" id=\"quform_1_70_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_70 quform-field-1_70_2\" value=\"No\" \/><label for=\"quform_1_70_a0eb20_2\" class=\"quform-option-label quform-option-label-1_70_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_76 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_76\"><label class=\"quform-label-text\" id=\"quform_1_76_a0eb20_label\">Unexplained fatigue\/malaise\/muscle aches<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_76\"><div class=\"quform-input quform-input-radio quform-input-1_76 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_76_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_76\" id=\"quform_1_76_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_76 quform-field-1_76_1\" value=\"Yes\" \/><label for=\"quform_1_76_a0eb20_1\" class=\"quform-option-label quform-option-label-1_76_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_76\" id=\"quform_1_76_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_76 quform-field-1_76_2\" value=\"No\" \/><label for=\"quform_1_76_a0eb20_2\" class=\"quform-option-label quform-option-label-1_76_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_67\"><div class=\"quform-element quform-element-radio quform-element-1_68 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_68\"><label class=\"quform-label-text\" id=\"quform_1_68_a0eb20_label\">Worsening chronic cough<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_68\"><div class=\"quform-input quform-input-radio quform-input-1_68 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_68_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_68\" id=\"quform_1_68_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_68 quform-field-1_68_1\" value=\"Yes\" \/><label for=\"quform_1_68_a0eb20_1\" class=\"quform-option-label quform-option-label-1_68_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_68\" id=\"quform_1_68_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_68 quform-field-1_68_2\" value=\"No\" \/><label for=\"quform_1_68_a0eb20_2\" class=\"quform-option-label quform-option-label-1_68_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_71 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_71\"><label class=\"quform-label-text\" id=\"quform_1_71_a0eb20_label\">Sore throat<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_71\"><div class=\"quform-input quform-input-radio quform-input-1_71 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_71_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_71\" id=\"quform_1_71_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_71 quform-field-1_71_1\" value=\"Yes\" \/><label for=\"quform_1_71_a0eb20_1\" class=\"quform-option-label quform-option-label-1_71_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_71\" id=\"quform_1_71_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_71 quform-field-1_71_2\" value=\"No\" \/><label for=\"quform_1_71_a0eb20_2\" class=\"quform-option-label quform-option-label-1_71_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_74 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_74\"><label class=\"quform-label-text\" id=\"quform_1_74_a0eb20_label\">Chills<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_74\"><div class=\"quform-input quform-input-radio quform-input-1_74 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_74_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_74\" id=\"quform_1_74_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_74 quform-field-1_74_1\" value=\"Yes\" \/><label for=\"quform_1_74_a0eb20_1\" class=\"quform-option-label quform-option-label-1_74_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_74\" id=\"quform_1_74_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_74 quform-field-1_74_2\" value=\"No\" \/><label for=\"quform_1_74_a0eb20_2\" class=\"quform-option-label quform-option-label-1_74_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_77 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_77\"><label class=\"quform-label-text\" id=\"quform_1_77_a0eb20_label\">Nausea\/vomiting, diarrhea, abdominal pain<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_77\"><div class=\"quform-input quform-input-radio quform-input-1_77 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_77_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_77\" id=\"quform_1_77_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_77 quform-field-1_77_1\" value=\"Yes\" \/><label for=\"quform_1_77_a0eb20_1\" class=\"quform-option-label quform-option-label-1_77_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_77\" id=\"quform_1_77_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_77 quform-field-1_77_2\" value=\"No\" \/><label for=\"quform_1_77_a0eb20_2\" class=\"quform-option-label quform-option-label-1_77_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_79 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_79\"><label class=\"quform-label-text\" id=\"quform_1_79_a0eb20_label\">Runny nose or nasal congestion without known cause<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_79\"><div class=\"quform-input quform-input-radio quform-input-1_79 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_79_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_79\" id=\"quform_1_79_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_79 quform-field-1_79_1\" value=\"Yes\" \/><label for=\"quform_1_79_a0eb20_1\" class=\"quform-option-label quform-option-label-1_79_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_79\" id=\"quform_1_79_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_79 quform-field-1_79_2\" value=\"No\" \/><label for=\"quform_1_79_a0eb20_2\" class=\"quform-option-label quform-option-label-1_79_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_45 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Age Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_46 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_47\"><div class=\"quform-element quform-element-radio quform-element-1_80 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_80\"><label class=\"quform-label-text\" id=\"quform_1_80_a0eb20_label\">Are you or any member for your household 70 years old or older?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_80\"><div class=\"quform-input quform-input-radio quform-input-1_80 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_80_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_80\" id=\"quform_1_80_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_80 quform-field-1_80_1\" value=\"Yes\" \/><label for=\"quform_1_80_a0eb20_1\" class=\"quform-option-label quform-option-label-1_80_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_80\" id=\"quform_1_80_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_80 quform-field-1_80_2\" value=\"No\" \/><label for=\"quform_1_80_a0eb20_2\" class=\"quform-option-label quform-option-label-1_80_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_91 quform-cf quform-group-style-bordered\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Is any member of your household older than 70 experiencing any of the following symptoms?<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_95 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_96\"><div class=\"quform-element quform-element-radio quform-element-1_97 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_97\"><label class=\"quform-label-text\" id=\"quform_1_97_a0eb20_label\">Delirium<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_97\"><div class=\"quform-input quform-input-radio quform-input-1_97 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_97_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_97\" id=\"quform_1_97_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_97 quform-field-1_97_1\" value=\"Yes\" \/><label for=\"quform_1_97_a0eb20_1\" class=\"quform-option-label quform-option-label-1_97_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_97\" id=\"quform_1_97_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_97 quform-field-1_97_2\" value=\"No\" \/><label for=\"quform_1_97_a0eb20_2\" class=\"quform-option-label quform-option-label-1_97_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_98 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_98\"><label class=\"quform-label-text\" id=\"quform_1_98_a0eb20_label\">Acute functional decline<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_98\"><div class=\"quform-input quform-input-radio quform-input-1_98 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_98_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_98\" id=\"quform_1_98_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_98 quform-field-1_98_1\" value=\"Yes\" \/><label for=\"quform_1_98_a0eb20_1\" class=\"quform-option-label quform-option-label-1_98_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_98\" id=\"quform_1_98_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_98 quform-field-1_98_2\" value=\"No\" \/><label for=\"quform_1_98_a0eb20_2\" class=\"quform-option-label quform-option-label-1_98_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_99\"><div class=\"quform-element quform-element-radio quform-element-1_100 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_100\"><label class=\"quform-label-text\" id=\"quform_1_100_a0eb20_label\">Unexplained or increased number of falls<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_100\"><div class=\"quform-input quform-input-radio quform-input-1_100 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_100_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_100\" id=\"quform_1_100_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_100 quform-field-1_100_1\" value=\"Yes\" \/><label for=\"quform_1_100_a0eb20_1\" class=\"quform-option-label quform-option-label-1_100_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_100\" id=\"quform_1_100_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_100 quform-field-1_100_2\" value=\"No\" \/><label for=\"quform_1_100_a0eb20_2\" class=\"quform-option-label quform-option-label-1_100_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_101 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_101\"><label class=\"quform-label-text\" id=\"quform_1_101_a0eb20_label\">Worsening of chronic conditions<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_101\"><div class=\"quform-input quform-input-radio quform-input-1_101 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_101_a0eb20_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_101\" id=\"quform_1_101_a0eb20_1\" class=\"quform-field quform-field-radio quform-field-1_101 quform-field-1_101_1\" value=\"Yes\" \/><label for=\"quform_1_101_a0eb20_1\" class=\"quform-option-label quform-option-label-1_101_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_101\" id=\"quform_1_101_a0eb20_2\" class=\"quform-field quform-field-radio quform-field-1_101 quform-field-1_101_2\" value=\"No\" \/><label for=\"quform_1_101_a0eb20_2\" class=\"quform-option-label quform-option-label-1_101_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-1_36 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Submit Report<\/h4><p class=\"quform-group-description\">By submitting this form you are confirming that to the best of your knowledge all of the information provided is correct.\n\nThank you for helping us protect one another from COVID-19.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-1_37 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_38\"><div class=\"quform-element quform-element-recaptcha quform-element-1_35 quform-cf quform-element-required quform-recaptcha-no-size\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-recaptcha quform-inner-1_35\"><div class=\"quform-input quform-input-recaptcha 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