Buckeye ALS Transport

[date name="variable_1" default="02/01/2019"]

Dispatched Unit
[radio name="Dispatched Unit" value="Unit 21-01|Unit 22-01|Unit 23-01"]

Was this scheduled?
[select name="pre_scheduled" value="|Pre-Scheduled|Non Scheduled"]

Origin Facility
[select name="Origin Facility Name" value="|Clinton Memorial Hospital (Wilmington)|Highland District Hospital (Hillsboro)|Adena Greenfield Medical Center (Greenfield)|Adena Regional Medical Center (Chillicothe)|Miami Valley Hospital (Dayton)|UC Hospital (Cincinnati)|Bethesda North (Cincinnati)"]

Origin Department
[select name="Origin Facility Department" value="|Emergency Room|Telemetry Unit|Cardiac Unit"]


Dispatched Unit


Was this scheduled?


Origin Facility


Origin Department

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 1, 5 form elements, 9 boilerplate words, 1 dates, 1 radio buttons, 3 drop downs, 5 total clicks
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