{"id":7,"date":"2016-10-23T15:39:40","date_gmt":"2016-10-23T20:39:40","guid":{"rendered":"http:\/\/cdacforms.com\/?page_id=7"},"modified":"2017-08-28T15:57:20","modified_gmt":"2017-08-28T20:57:20","slug":"incident-form","status":"publish","type":"page","link":"https:\/\/cdacforms.com\/index.php\/incident-form\/","title":{"rendered":"CDAC Internal Use"},"content":{"rendered":"<body><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 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<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Incident Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php\/wp-json\/wp\/v2\/pages\/7' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_2\" 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_1_2'>Programs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_2' id='input_1_2' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='WISE' >WISE<\/option><option value='RISE-Escambia' >RISE-Escambia<\/option><option value='RISE-SR' >RISE-SR<\/option><option value='ECHO' >ECHO<\/option><option value='ECHO-PPG' >ECHO-PPG<\/option><option value='BOOST' >BOOST<\/option><option value='Prevention' >Prevention<\/option><option value='Administration' >Administration<\/option><\/select><\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-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_1_3'>Date<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_3' id='input_1_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_3' class='gform_hidden' value='https:\/\/cdacforms.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-time 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' >Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_4'>\n                            <input type='number' name='input_4[]' id='input_1_4_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_4_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_4[]' id='input_1_4_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_4_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_4[]' id='input_1_4_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_1_4_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_1_5\" 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' for='input_1_5'>Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_6\" 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' for='input_1_6'>Client ID\/#<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_6\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_6'>NO CLIENTS NAME<\/div><\/li><li id=\"field_1_7\" 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' for='input_1_7'>Reported by:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_7\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_7'>your first name last name<\/div><\/li><li id=\"field_1_9\" 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\"  ><label class='gfield_label gform-field-label' >Notifications-1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_9'>\n\t\t\t<li class='gchoice gchoice_1_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Protective Service'  id='choice_1_9_0'    \/>\n\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>Protective Service<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Supervisor\/Director'  id='choice_1_9_1'    \/>\n\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>Supervisor\/Director<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_2'>\n\t\t\t\t<input name='input_9' type='radio' value='Executive Director'  id='choice_1_9_2'    \/>\n\t\t\t\t<label for='choice_1_9_2' id='label_1_9_2' class='gform-field-label gform-field-label--type-inline'>Executive Director<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_3'>\n\t\t\t\t<input name='input_9' type='radio' value='Parent\/Gaurdian'  id='choice_1_9_3'    \/>\n\t\t\t\t<label for='choice_1_9_3' id='label_1_9_3' class='gform-field-label gform-field-label--type-inline'>Parent\/Gaurdian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_4'>\n\t\t\t\t<input name='input_9' type='radio' value='Law Enforcment'  id='choice_1_9_4'    \/>\n\t\t\t\t<label for='choice_1_9_4' id='label_1_9_4' class='gform-field-label gform-field-label--type-inline'>Law Enforcment<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_9_5'>\n\t\t\t\t<input name='input_9' type='radio' value='gf_other_choice'  id='choice_1_9_5'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_9_other' name='input_9_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-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_1_10'>Date of Notification-1<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_10' id='input_1_10' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_10' class='gform_hidden' value='https:\/\/cdacforms.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-time 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' >Time of Notification-1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_11'>\n                            <input type='number' name='input_11[]' id='input_1_11_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_11_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_11[]' id='input_1_11_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_11_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_11[]' id='input_1_11_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_1_11_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_1_12\" 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\"  ><label class='gfield_label gform-field-label' >Notifications-2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_12'>\n\t\t\t<li class='gchoice gchoice_1_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Protective Service'  id='choice_1_12_0'    \/>\n\t\t\t\t<label for='choice_1_12_0' id='label_1_12_0' class='gform-field-label gform-field-label--type-inline'>Protective Service<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Supervisor\/Director'  id='choice_1_12_1'    \/>\n\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>Supervisor\/Director<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Executive Director'  id='choice_1_12_2'    \/>\n\t\t\t\t<label for='choice_1_12_2' id='label_1_12_2' class='gform-field-label gform-field-label--type-inline'>Executive Director<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_12_3'>\n\t\t\t\t<input name='input_12' type='radio' value='Parent\/Gaurdian'  id='choice_1_12_3'    \/>\n\t\t\t\t<label for='choice_1_12_3' id='label_1_12_3' class='gform-field-label gform-field-label--type-inline'>Parent\/Gaurdian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_12_4'>\n\t\t\t\t<input name='input_12' type='radio' value='Law Enforcment'  id='choice_1_12_4'    \/>\n\t\t\t\t<label for='choice_1_12_4' id='label_1_12_4' class='gform-field-label gform-field-label--type-inline'>Law Enforcment<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_12_5'>\n\t\t\t\t<input name='input_12' type='radio' value='gf_other_choice'  id='choice_1_12_5'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_12_other' name='input_12_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-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_1_13'>Date of Notification-2<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_13' id='input_1_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_13_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_13' class='gform_hidden' value='https:\/\/cdacforms.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-time 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' >Time of Notification-2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_1_14'>\n                            <input type='number' name='input_14[]' id='input_1_14_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_1_14_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_14[]' id='input_1_14_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_1_14_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_14[]' id='input_1_14_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_1_14_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_1_15\" 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\"  ><label class='gfield_label gform-field-label' >Type of Incident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_15'>\n\t\t\t<li class='gchoice gchoice_1_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Abuse\/neglect\/Exploitation Please call 1-800-962-2873 (1-800-96-ABUSE)'  id='choice_1_15_0'    \/>\n\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Extreme - Abuse\/neglect\/Exploitation Please call 1-800-962-2873 (1-800-96-ABUSE)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Client injury or ill (Hospital Admission)'  id='choice_1_15_1'    \/>\n\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Extreme - Client injury or ill (Hospital Admission)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Altercation \u2013 Medical Care Needed'  id='choice_1_15_2'    \/>\n\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>Extreme - Altercation \u2013 Medical Care Needed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_3'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Negative Media Issue'  id='choice_1_15_3'    \/>\n\t\t\t\t<label for='choice_1_15_3' id='label_1_15_3' class='gform-field-label gform-field-label--type-inline'>Extreme - Negative Media Issue<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_4'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Client Death'  id='choice_1_15_4'    \/>\n\t\t\t\t<label for='choice_1_15_4' id='label_1_15_4' class='gform-field-label gform-field-label--type-inline'>Extreme - Client Death<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_5'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Elopement'  id='choice_1_15_5'    \/>\n\t\t\t\t<label for='choice_1_15_5' id='label_1_15_5' class='gform-field-label gform-field-label--type-inline'>Extreme - Elopement<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_6'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Escape'  id='choice_1_15_6'    \/>\n\t\t\t\t<label for='choice_1_15_6' id='label_1_15_6' class='gform-field-label gform-field-label--type-inline'>Extreme - Escape<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_7'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Suicide Attempt'  id='choice_1_15_7'    \/>\n\t\t\t\t<label for='choice_1_15_7' id='label_1_15_7' class='gform-field-label gform-field-label--type-inline'>Extreme - Suicide Attempt<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_8'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Client to client Sexual Battery'  id='choice_1_15_8'    \/>\n\t\t\t\t<label for='choice_1_15_8' id='label_1_15_8' class='gform-field-label gform-field-label--type-inline'>Extreme - Client to client Sexual Battery<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_9'>\n\t\t\t\t<input name='input_15' type='radio' value='Extreme - Other --Brief Descript in the text box below--'  id='choice_1_15_9'    \/>\n\t\t\t\t<label for='choice_1_15_9' id='label_1_15_9' class='gform-field-label gform-field-label--type-inline'>Extreme - Other --Brief Descript in the text box below--<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_10'>\n\t\t\t\t<input name='input_15' type='radio' value='Moderate - Client Grievance'  id='choice_1_15_10'    \/>\n\t\t\t\t<label for='choice_1_15_10' id='label_1_15_10' class='gform-field-label gform-field-label--type-inline'>Moderate - Client Grievance<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_11'>\n\t\t\t\t<input name='input_15' type='radio' value='Moderate - Witnessed client illness\/injury (ER released)'  id='choice_1_15_11'    \/>\n\t\t\t\t<label for='choice_1_15_11' id='label_1_15_11' class='gform-field-label gform-field-label--type-inline'>Moderate - Witnessed client illness\/injury (ER released)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_12'>\n\t\t\t\t<input name='input_15' type='radio' value='Moderate - Witnessed client illness\/injury (1st aid or less)'  id='choice_1_15_12'    \/>\n\t\t\t\t<label for='choice_1_15_12' id='label_1_15_12' class='gform-field-label gform-field-label--type-inline'>Moderate - Witnessed client illness\/injury (1st aid or less)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_13'>\n\t\t\t\t<input name='input_15' type='radio' value='Moderate - Physical Altercation 1st aid or less, between client or with staff)'  id='choice_1_15_13'    \/>\n\t\t\t\t<label for='choice_1_15_13' id='label_1_15_13' class='gform-field-label gform-field-label--type-inline'>Moderate - Physical Altercation 1st aid or less, between client or with staff)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_14'>\n\t\t\t\t<input name='input_15' type='radio' value='Moderate - Threats by client(s) \u2013If immediate danger, treat as Extreme, under other'  id='choice_1_15_14'    \/>\n\t\t\t\t<label for='choice_1_15_14' id='label_1_15_14' class='gform-field-label gform-field-label--type-inline'>Moderate - Threats by client(s) \u2013If immediate danger, treat as Extreme, under other<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_15'>\n\t\t\t\t<input name='input_15' type='radio' value='Moderate - Active suicide Ideation\/Threat'  id='choice_1_15_15'    \/>\n\t\t\t\t<label for='choice_1_15_15' id='label_1_15_15' class='gform-field-label gform-field-label--type-inline'>Moderate - Active suicide Ideation\/Threat<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_16'>\n\t\t\t\t<input name='input_15' type='radio' value='Moderate - Other --Brief Descript in the text box below--'  id='choice_1_15_16'    \/>\n\t\t\t\t<label for='choice_1_15_16' id='label_1_15_16' class='gform-field-label gform-field-label--type-inline'>Moderate - Other --Brief Descript in the text box below--<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_17'>\n\t\t\t\t<input name='input_15' type='radio' value='Staff - Vehicle Accident while on Duty \u2013 accident with injury treat as Extreme, under Other (must also complete drug\/alcohol tests, see P&amp;P 801)'  id='choice_1_15_17'    \/>\n\t\t\t\t<label for='choice_1_15_17' id='label_1_15_17' class='gform-field-label gform-field-label--type-inline'>Staff - Vehicle Accident while on Duty \u2013 accident with injury treat as Extreme, under Other (must also complete drug\/alcohol tests, see P&P 801)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_18'>\n\t\t\t\t<input name='input_15' type='radio' value='Staff - Damage of Personal or Agency\u2019s property'  id='choice_1_15_18'    \/>\n\t\t\t\t<label for='choice_1_15_18' id='label_1_15_18' class='gform-field-label gform-field-label--type-inline'>Staff - Damage of Personal or Agency\u2019s property<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_19'>\n\t\t\t\t<input name='input_15' type='radio' value='Staff - Theft of Personal or Agency property'  id='choice_1_15_19'    \/>\n\t\t\t\t<label for='choice_1_15_19' id='label_1_15_19' class='gform-field-label gform-field-label--type-inline'>Staff - Theft of Personal or Agency property<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_20'>\n\t\t\t\t<input name='input_15' type='radio' value='Staff - Employee injury \u2013 Must also do Worker\u2019s Com report'  id='choice_1_15_20'    \/>\n\t\t\t\t<label for='choice_1_15_20' id='label_1_15_20' class='gform-field-label gform-field-label--type-inline'>Staff - Employee injury \u2013 Must also do Worker\u2019s Com report<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_21'>\n\t\t\t\t<input name='input_15' type='radio' value='Staff - Other --Brief Descript in the text box below--'  id='choice_1_15_21'    \/>\n\t\t\t\t<label for='choice_1_15_21' id='label_1_15_21' class='gform-field-label gform-field-label--type-inline'>Staff - Other --Brief Descript in the text box 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