{"id":7782,"date":"2022-12-02T13:59:12","date_gmt":"2022-12-02T21:59:12","guid":{"rendered":"https:\/\/www.bellevuecollege.edu\/publicsafety\/?page_id=7782"},"modified":"2023-02-14T13:05:51","modified_gmt":"2023-02-14T21:05:51","slug":"accident-injury-report-form","status":"publish","type":"page","link":"https:\/\/www.bellevuecollege.edu\/publicsafety\/accident-injury-report-form\/","title":{"rendered":"Employee Accident\/Injury Report Form"},"content":{"rendered":"<script>\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 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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<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_136' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Accident Injury Report (Employee)<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_136'  action='\/publicsafety\/wp-json\/wp\/v2\/pages\/7782' data-formid='136' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_136' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_136_55\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_55'><span class='gform-field-label__text'>Company<\/span><\/label><div class='ginput_container'><input name='input_55' id='input_136_55' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_136_55'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_136_3\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Reporting Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_136_3' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_136_3_1_container'>\n                                        <input type='number' maxlength='2' name='input_3[]' id='input_136_3_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_136_3_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_136_3_2_container'>\n                                        <input type='number' maxlength='2' name='input_3[]' id='input_136_3_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <label for='input_136_3_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                    <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_136_3_3_container'>\n                                        <input type='number' maxlength='4' name='input_3[]' id='input_136_3_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_136_3_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                               <\/div><\/fieldset><fieldset id=\"field_136_6\" class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Time<\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_136_6'>\n                            <input type='number' name='input_6[]' id='input_136_6_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_136_6_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"above hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_6[]' id='input_136_6_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_136_6_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time above gform-grid-col' >\n                                \n                                <select name='input_6[]' id='input_136_6_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_136_6_3'>AM\/PM<\/label>\n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_136_8\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_8'><span class='gform-field-label__text'>Public Safety Case Number (if known)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_136_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_136_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gender<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_23'>\n\t\t\t<div class='gchoice gchoice_136_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Male'  id='choice_136_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_23_0' id='label_136_23_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Female'  id='choice_136_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_23_1' id='label_136_23_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Non-Binary'  id='choice_136_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_23_2' id='label_136_23_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_23_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Prefer Not to Disclose'  id='choice_136_23_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_23_3' id='label_136_23_3' class='gform-field-label gform-field-label--type-inline'>Prefer Not to Disclose<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_136_39\" class=\"gfield gfield--type-text gfield--width-third 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_136_39'><span class='gform-field-label__text'>ctcLink Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_136_39' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_136_1\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_136_1'>\n                            \n                            <span id='input_136_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_136_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_136_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_136_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_136_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_136_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_136_32\" class=\"gfield gfield--type-email gfield--width-seven-twelfths 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_136_32'><span class='gform-field-label__text'>Bellevue College Email Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_32' id='input_136_32' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_136_33\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-five-twelfths 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_136_33'><span class='gform-field-label__text'>Bellevue College Phone\/ Extension<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_136_33' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_136_38\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-full 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_136_38'><span class='gform-field-label__text'>Contact Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_136_38' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_136_11\" class=\"gfield gfield--type-text gfield--width-seven-twelfths 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_136_11'><span class='gform-field-label__text'>Department<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_136_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_136_16\" class=\"gfield gfield--type-text gfield--width-five-twelfths 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_136_16'><span class='gform-field-label__text'>Supervisor<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_136_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_136_14\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Home Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_136_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_136_14_1_container' >\n                                        <input type='text' name='input_14.1' id='input_136_14_1' value=''    aria-required='false'    \/>\n                                        <label for='input_136_14_1' id='input_136_14_1_label' class='gform-field-label gform-field-label--type-sub '>Street<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_136_14_2_container' >\n                                        <input type='text' name='input_14.2' id='input_136_14_2' value=''     aria-required='false'   \/>\n                                        <label for='input_136_14_2' id='input_136_14_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_136_14_3_container' >\n                                    <input type='text' name='input_14.3' id='input_136_14_3' value=''    aria-required='false'    \/>\n                                    <label for='input_136_14_3' id='input_136_14_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_136_14_4_container' >\n                                        <input type='text' name='input_14.4' id='input_136_14_4' value=''      aria-required='false'    \/>\n                                        <label for='input_136_14_4' id='input_136_14_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_136_14_5_container' >\n                                    <input type='text' name='input_14.5' id='input_136_14_5' value=''    aria-required='false'    \/>\n                                    <label for='input_136_14_5' id='input_136_14_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_136_14_6_container' >\n                                        <select name='input_14.6' id='input_136_14_6'   aria-required='false'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_136_14_6' id='input_136_14_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_136_4\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Accident\/ Injury<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_136_4' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_136_4_1_container'>\n                                        <input type='number' maxlength='2' name='input_4[]' id='input_136_4_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_136_4_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_136_4_2_container'>\n                                        <input type='number' maxlength='2' name='input_4[]' id='input_136_4_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <label for='input_136_4_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                    <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_136_4_3_container'>\n                                        <input type='number' maxlength='4' name='input_4[]' id='input_136_4_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_136_4_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                               <\/div><\/fieldset><fieldset id=\"field_136_13\" class=\"gfield gfield--type-time gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Time of Accident\/ Injury<\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_136_13'>\n                            <input type='number' name='input_13[]' id='input_136_13_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_136_13_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"above hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_13[]' id='input_136_13_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_136_13_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time above gform-grid-col' >\n                                \n                                <select name='input_13[]' id='input_136_13_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_136_13_3'>AM\/PM<\/label>\n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_136_17\" class=\"gfield gfield--type-text gfield--width-third 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_136_17'><span class='gform-field-label__text'>Location of Accident\/ Injury<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_136_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_136_5\" class=\"gfield gfield--type-textarea gfield--width-full 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_136_5'><span class='gform-field-label__text'>What was the individual doing just before the incident occurred?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_136_5'>Describe the activity, as well as the tools, equipment, or materials the employee was using. Be specific. (Examples: \u201cclimbing a ladder while carrying roofing materials\u201d, \u201cspraying chlorine from hand sprayer\u201d, \u201csitting at desk in office typing\u201d, \u201cwalking back from a meeting\u201d.)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_136_5' class='textarea large'  aria-describedby=\"gfield_description_136_5\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_136_18\" class=\"gfield gfield--type-textarea gfield--width-full 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_136_18'><span class='gform-field-label__text'>Describe what happened.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_136_18'>How did the injury occur? (Examples: \u201cwhen ladder slipped on wet floor, employee fell 20 feet\u201d, \u201cemployee was sprayed with chlorine when gasket broke during replacement\u201d, \u201cwas moving boxes and one fell on foot\u201d, \u201cwalking down stairs and slipped and fell\u201d.)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_136_18' class='textarea large'  aria-describedby=\"gfield_description_136_18\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_136_37\" class=\"gfield gfield--type-textarea gfield--width-full 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_136_37'><span class='gform-field-label__text'>What was the injury or illness?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_136_37'>For example, which part of the body was affected and how it was affected? Be more specific than \u201churt\u201d, \u201cpain\u201d or \u201csore\u201d. (Examples: \u201cstrained back\u201d, \u201cchemical burn, sprained left wrist\u201d, \u201cboth eyes burning, etc\u201d.)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_136_37' class='textarea large'  aria-describedby=\"gfield_description_136_37\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_136_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Did the accident involve an eye injury to the Employee?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_50'>\n\t\t\t<div class='gchoice gchoice_136_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Yes'  id='choice_136_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_50_0' id='label_136_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_136_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_50_1' id='label_136_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Unsure'  id='choice_136_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_50_2' id='label_136_50_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_19\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Witness Name<\/span><\/legend><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_136_19'>\n                            \n                            <span id='input_136_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.3' id='input_136_19_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_136_19_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_136_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.6' id='input_136_19_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_136_19_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_136_15\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_15'><span class='gform-field-label__text'>Witness Phone Number<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_136_15' type='text' value='' class='large'    placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><\/div><div id=\"field_136_34\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_34'><span class='gform-field-label__text'>Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_136_34' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_136_20\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Witness Name<\/span><\/legend><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_136_20'>\n                            \n                            <span id='input_136_20_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.3' id='input_136_20_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_136_20_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_136_20_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.6' id='input_136_20_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_136_20_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_136_21\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_21'><span class='gform-field-label__text'>Witness Phone Number<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_136_21' type='text' value='' class='large'    placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\"\/><\/div><\/div><div id=\"field_136_35\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_35'><span class='gform-field-label__text'>Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_35' id='input_136_35' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_136_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Is this report being filed by a witness?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_22'>\n\t\t\t<div class='gchoice gchoice_136_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_136_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_22_0' id='label_136_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_136_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_22_1' id='label_136_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>If this report is being filed by a witness, will the injured employee file a report?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_24'>\n\t\t\t<div class='gchoice gchoice_136_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_136_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_24_0' id='label_136_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_136_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_24_1' id='label_136_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Was First Aid Given?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_25'>\n\t\t\t<div class='gchoice gchoice_136_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_136_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_25_0' id='label_136_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_136_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_25_1' id='label_136_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Unknown'  id='choice_136_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_25_2' id='label_136_25_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_136_27\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_27'><span class='gform-field-label__text'>By whom?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_136_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_136_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Did the Employee leave work to see about their injury?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_29'>\n\t\t\t<div class='gchoice gchoice_136_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_136_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_29_0' id='label_136_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_136_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_29_1' id='label_136_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Unknown'  id='choice_136_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_29_2' id='label_136_29_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Did the Employee seek any kind of treatment for this injury?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_54'>\n\t\t\t<div class='gchoice gchoice_136_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_136_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_54_0' id='label_136_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_136_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_54_1' id='label_136_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Unknown'  id='choice_136_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_54_2' id='label_136_54_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Did the Employee go to the Emergency Room?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_26'>\n\t\t\t<div class='gchoice gchoice_136_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_136_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_26_0' id='label_136_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_136_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_26_1' id='label_136_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Unknown'  id='choice_136_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_26_2' id='label_136_26_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Did the Employee go to the Emergency Room Immediately?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_44'>\n\t\t\t<div class='gchoice gchoice_136_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_136_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_44_0' id='label_136_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_136_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_44_1' id='label_136_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Unknown'  id='choice_136_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_44_2' id='label_136_44_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_42\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date the Employee went to the Emergency Room<\/span><\/legend><div id='input_136_42' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_136_42_1_container'>\n                                        <input type='number' maxlength='2' name='input_42[]' id='input_136_42_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_136_42_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_136_42_2_container'>\n                                        <input type='number' maxlength='2' name='input_42[]' id='input_136_42_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <label for='input_136_42_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                    <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_136_42_3_container'>\n                                        <input type='number' maxlength='4' name='input_42[]' id='input_136_42_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_136_42_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                               <\/div><\/fieldset><fieldset id=\"field_136_43\" class=\"gfield gfield--type-time gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Time the Employee went to the Emergency Room<\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_136_43'>\n                            <input type='number' name='input_43[]' id='input_136_43_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_136_43_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"above hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_43[]' id='input_136_43_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_136_43_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time above gform-grid-col' >\n                                \n                                <select name='input_43[]' id='input_136_43_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_136_43_3'>AM\/PM<\/label>\n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_136_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Did the Employee return to work?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_30'>\n\t\t\t<div class='gchoice gchoice_136_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_136_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_30_0' id='label_136_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_136_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_30_1' id='label_136_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Unknown'  id='choice_136_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_30_2' id='label_136_30_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_53\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date Employee Returned to Work<\/span><\/legend><div id='input_136_53' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_136_53_1_container'>\n                                        <input type='number' maxlength='2' name='input_53[]' id='input_136_53_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_136_53_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                    <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_136_53_2_container'>\n                                        <input type='number' maxlength='2' name='input_53[]' id='input_136_53_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <label for='input_136_53_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                    <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_136_53_3_container'>\n                                        <input type='number' maxlength='4' name='input_53[]' id='input_136_53_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_136_53_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                               <\/div><\/fieldset><fieldset id=\"field_136_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Was the Employee hospitalized as a result of their injury?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_28'>\n\t\t\t<div class='gchoice gchoice_136_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_136_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_28_0' id='label_136_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_136_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_28_1' id='label_136_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Unknown'  id='choice_136_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_28_2' id='label_136_28_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_136_47\" class=\"gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_47'><span class='gform-field-label__text'>How long was the Employee hospitalized for?<\/span><\/label><div class='ginput_container ginput_container_text' data-text-counter-max='50' data-text-counter-template='{current} of {max} max characters'><input name='input_47' id='input_136_47' type='text' value='' class='large' maxlength='50'     aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_136_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Was an amputation part of the Employee&#039;s treatment for their injury?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_51'>\n\t\t\t<div class='gchoice gchoice_136_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Yes'  id='choice_136_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_51_0' id='label_136_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_136_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_51_1' id='label_136_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Unsure'  id='choice_136_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_51_2' id='label_136_51_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_136_52\" class=\"gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_136_52'><span class='gform-field-label__text'>If known, which extremity was involved?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_136_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_136_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Is the Employee deceased?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_136_48'>\n\t\t\t<div class='gchoice gchoice_136_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_136_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_48_0' id='label_136_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_136_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_48_1' id='label_136_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_136_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Unknown'  id='choice_136_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_136_48_2' id='label_136_48_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_136_49\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>If known, please provide the date of death.<\/span><\/legend><div id='input_136_49' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_136_49_1_container'>\n                                        <input type='number' maxlength='2' name='input_49[]' id='input_136_49_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_136_49_1' class='gform-field-label 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