{"id":1394,"date":"2016-08-22T15:05:12","date_gmt":"2016-08-22T20:05:12","guid":{"rendered":"https:\/\/uwm.edu\/bms-labs\/?page_id=1394"},"modified":"2024-06-25T15:34:07","modified_gmt":"2024-06-25T20:34:07","slug":"student-accident-incident-report-form","status":"publish","type":"page","link":"https:\/\/uwm.edu\/bms-labs\/student-accident-incident-report-form\/","title":{"rendered":"BMS Accident Incident Report Form"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-582  alignright\" src=\"https:\/\/uwm.edu\/bms-labs\/wp-content\/uploads\/sites\/361\/2013\/10\/BMS-Labs.jpg\" alt=\"\" width=\"350\" height=\"100\" srcset=\"https:\/\/uwm.edu\/bms-labs\/wp-content\/uploads\/sites\/361\/2013\/10\/BMS-Labs.jpg 589w, https:\/\/uwm.edu\/bms-labs\/wp-content\/uploads\/sites\/361\/2013\/10\/BMS-Labs-300x86.jpg 300w\" sizes=\"auto, (max-width: 350px) 100vw, 350px\" \/><\/p>\n<p style=\"text-align: center\"><span style=\"color: #ffffff\"><strong>.<\/strong><\/span><\/p>\n<p style=\"text-align: center\"><span style=\"color: #ffffff\"><strong>.<\/strong><\/span><\/p>\n<p style=\"text-align: center\"><strong>For ALL emergencies, contact Campus Police-<\/strong><br \/>\n<strong> 9-911 from a campus phone or 229-9911 from a cell phone.<\/strong><\/p>\n<p style=\"text-align: center\">If this incident involves any type of personal injury or property damage, additional campus reports must also be completed.\u00a0 Please see the <a href=\"https:\/\/uwm.edu\/bms-labs\/accident-incident-and-injury-reporting\/\" rel=\"noopener\" target=\"_blank\">Accident, Incident, and Injury Reporting<\/a> page for instructions on proper incident reporting.\u00a0 If you are unsure if you need additional report forms, contact your instructor, supervisor, PI, or <a href=\"https:\/\/uwm.edu\/bms-labs\/contact-us\/\" rel=\"noopener\" target=\"_blank\">click here to Contact Us<\/a>.<\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_60' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">BMS Accident\/Incident Report Form<\/h3>\n                            <p class='gform_description'>Report is sent to the Laboratory Manager, and will be forwarded to the appropriate Department of Biomedical Sciences program director and placed in the student file (if applicable).<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_60'  action='\/bms-labs\/wp-json\/wp\/v2\/pages\/1394' data-formid='60' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Let4LkmAAAAAMDytJZITec55NB97k2BiShMXqPE' data-tabindex='0'><input id=\"input_6f787e6ddf316a4674909a60a958174d\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_6f787e6ddf316a4674909a60a958174d\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><ul id='gform_fields_60' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_60_25\" class=\"gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_25' id='input_60_25' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='BMS Accident\/Incident Report' \/><\/div><\/li><li id=\"field_60_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_60_1'>\n                            \n                            <span id='input_60_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_60_1_3' value=''   aria-required='true'   placeholder='Type Here'  \/>\n                                                    <label for='input_60_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_60_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_60_1_6' value=''   aria-required='true'   placeholder='Type Here'  \/>\n                                                    <label for='input_60_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_60_2\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_2'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_2' id='input_60_2' type='tel' value='' class='small'  placeholder='(###) ###-####' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_60_3\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_60_3' type='email' value='' class='small'   placeholder='Type Here' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_60_3\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_60_3'>------------------------------------------------------------------<\/div><\/li><li id=\"field_60_9\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_9'>Date of Incident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_60_9' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_60_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_60_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_60_9' class='gform_hidden' value='https:\/\/uwm.edu\/bms-labs\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_60_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_7'>Approximate Time of Incident<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_60_7' type='text' value='' class='medium'  aria-describedby=\"gfield_description_60_7\"  placeholder='Type Here'  aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_60_7'>------------------------------------------------------------------<\/div><\/li><li id=\"field_60_21\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_21'>What is your role at 51ÁÔÆæ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_60_21'>If you fit multiple roles, chose the one in which you were working when the incident occurred.<\/div><div class='ginput_container ginput_container_select'><select name='input_21' id='input_60_21' class='medium gfield_select'  aria-describedby=\"gfield_description_60_21\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Employee' >Employee<\/option><option value='Student, Graduate (masters, PhD)' >Student, Graduate (masters, PhD)<\/option><option value='Student, Undergraduate (Biomedical Sciences)' >Student, Undergraduate (Biomedical Sciences)<\/option><option value='Student, Undergraduate (Diagnostic Medical Imaging)' >Student, Undergraduate (Diagnostic Medical Imaging)<\/option><option value='Teaching Assistant' >Teaching Assistant<\/option><option value='Volunteer\/Visitor\/Guest' >Volunteer\/Visitor\/Guest<\/option><option value='Workstudy' >Workstudy<\/option><\/select><\/div><\/li><li id=\"field_60_23\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_23'>Did this incident happen during or while preparing for a class?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_60_23' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_60_4\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_4'>Instructor of course<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_60_4' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Shahla Anders' >Shahla Anders<\/option><option value='Brad De Pons' >Brad De Pons<\/option><option value='Dr. Zac Lunak' >Dr. Zac Lunak<\/option><option value='Dr. Jennifer Doll' >Dr. Jennifer Doll<\/option><option value='Dr. Janis Eells' >Dr. Janis Eells<\/option><option value='Dr. Elizabeth Liedhegner' >Dr. Elizabeth Liedhegner<\/option><option value='Dr. Dean Nardelli' >Dr. Dean Nardelli<\/option><option value='Dr. Troy Skwor' >Dr. Troy Skwor<\/option><option value='Other (please specify below)' >Other (please specify below)<\/option><\/select><\/div><\/li><li id=\"field_60_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_60_10'>Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_60_10' type='text' value='' class='small'    placeholder='Other' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_60_5\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_5'>Course #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_60_5' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='BMS 101 - Intro to Clinical Lab Sciences' >BMS 101 - Intro to Clinical Lab Sciences<\/option><option value='BMS 428 - Clinical Immunology Lab' >BMS 428 - Clinical Immunology Lab<\/option><option value='BMS 421 - Intro to Hematology Lab' >BMS 421 - Intro to Hematology Lab<\/option><option value='BMS 521 - Applied Clinical Hematology' >BMS 521 - Applied Clinical Hematology<\/option><option value='BMS 522 - Hemostasis' >BMS 522 - Hemostasis<\/option><option value='BMS 530 Immunohematology\/Blood Bank Lab' >BMS 530 Immunohematology\/Blood Bank Lab<\/option><option value='BMS 535 - Medical Microbiology Lab' selected='selected'>BMS 535 - Medical Microbiology Lab<\/option><option value='BMS 536 -  Applied Clinical Microbiology' >BMS 536 -  Applied Clinical Microbiology<\/option><option value='BMS 537 - Medical Parasitology &amp; Mycology' >BMS 537 - Medical Parasitology &amp; Mycology<\/option><option value='BMS 541 - Urinalysis' >BMS 541 - Urinalysis<\/option><option value='BMS 542 - Applied Clinical Chemistry' >BMS 542 - Applied Clinical Chemistry<\/option><option value='BMS 561 - Molecular Diagnostics Lab' >BMS 561 - Molecular Diagnostics Lab<\/option><option value='DMS Scan Lab' >DMS Scan Lab<\/option><option value='DMS Clinical Site' >DMS Clinical Site<\/option><option value='Other - Please specify below' >Other - Please specify below<\/option><\/select><\/div><\/li><li id=\"field_60_24\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_60_24'>Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_60_24' type='text' value='' class='small'  aria-describedby=\"gfield_description_60_24\"  placeholder='Other' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_60_24'>------------------------------------------------------------------<\/div><\/li><li id=\"field_60_6\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_6'>Description of injury\/incident:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_6' id='input_60_6' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_60_22\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_22'>Does this incident involve an exposure to blood, body fluids, or other potentially infectious material?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_60_22' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_60_13\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_13'>Source of Exposure (ex. blood, urine, CSF, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_60_13'>Please include identification of source, if available (name, number, email, etc.)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_60_13' class='textarea medium'  aria-describedby=\"gfield_description_60_13\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_60_11\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_11'>Could this incident have been prevented?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_60_11' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/li><li id=\"field_60_8\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_8'>Please describe how this could have been prevented.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_60_8' class='textarea medium'  aria-describedby=\"gfield_description_60_8\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_60_8'>------------------------------------------------------------------<\/div><\/li><li id=\"field_60_12\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_12'>Were any safety rules violated?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_60_12' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/li><li id=\"field_60_14\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_14'>Please describe which safety rules were violated.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_60_14' class='textarea medium'  aria-describedby=\"gfield_description_60_14\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_60_14'>------------------------------------------------------------------<\/div><\/li><li id=\"field_60_15\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_15'>Please list any pertinent witnesses below, including contact information<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_60_15' class='textarea medium'  aria-describedby=\"gfield_description_60_15\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_60_15'>------------------------------------------------------------------<\/div><\/li><li id=\"field_60_17\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_17'>Was any treatment rendered?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_60_17' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_60_16\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_16'>What treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_60_16' class='textarea medium'  aria-describedby=\"gfield_description_60_16\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_60_16'>------------------------------------------------------------------<\/div><\/li><li id=\"field_60_18\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_18'>Was person referred to a clinic or hospital?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_60_18' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_60_19\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_60_19'>Which clinic or hospital?<span class=\"gfield_required\"><span 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