RTW COVID

[comment memo="All dates must be entered as mm-dd-yyyy, if you do not use the drop down calendar. mm/dd/yyyy format will not work. If you don't want to enter dates, leave the field blank and nothing will populate (this is for the vaccines in questions 11 and 12."]
SUBJECTIVE:
[select name="variable_1" value="Mr.|Ms.|Mrs"][text name="variable_2" default=" "] presents to return to work from COVID-19 illness.1. Last Day Worked: [date name="variable_3" default="mm-dd-yyyy"]
2. When did your symptoms first appear:[date name="Variable_4" default="mm-dd-yyyy"]
3. What date did you test positive:[date name="variable_5" default="mm-dd-yyyy"]
4. Have you taken any medication in the last 24 hours for fever:[select name="variable_6" value="No|Yes"]
5. Attending provider: [text name="variable_7" default=""] [comment memo="PMD or PCP Name"]
6. Type of absence:[select name="variable_8" value="Non-occupational|Occupational(work-related)"]
7. Medical Diagnosis: B97.2 Coronavirus as the cause of diseases classified elsewhere
8. Hospitalized:[select name="variable_9" value="No|Yes"]
9. Provider's written RTW note: [select name="variable_10" value="Returned to work per plant medical's direction.|Yes|No"]
10. Dates coincide with sick leave: [select name="variable_11" value="Yes|No|N/a"]
11. Have you received COVID-19 vaccination, primary dose(s): [select name="variable_12" value="No|Yes|Declines to answer"]
If yes, what type: [select name="variable_13" value="N/a|Pfizer BioNTech|Moderna|JJ|AstraZeneca|NovaVax"]
Dates: [comment memo="Leave the next field blank if you have dates or select N/a if no dates."][select name="variable_14" value=" |N/a"] [date name="variable_15" default=" "] [date name="variable_16" default=" "]
Have you received COVID-19 vaccination, booster dose(s): [select name="variable_17" value="No|Yes|Declines to answer"]
If yes, what type: [select name="variable_18" value="N/a|Pfizer BioNTech|Moderna|JJ|AstraZeneca|NovaVax"]
Dates: [comment memo="Leave the next field blank if you have dates or select N/a if no dates."] [select name="variable_19" value=" |N/a"] [date name="variable_20" default=" "] [date name="variable_21" default=" "] [date name="variable_22" default=" "]
12. Shift:[select name="variable_23" value=" |1st|2nd|3rd"]
    Department:[select name="Variable_24" value=" |17-Trim|25-Chassis|15-Paint|45-Paint|10-Stamping|12-Stamping|42-Stamping|11-Body Shop|43-Body Shop|45-Skilled Trades|47-Skilled Trades|50-Material|70-Quality|40-Central Engineering|48-Central Engineering|44-Power House|75-Engineering|80-Salaried Personnel|81-Health Services|85-UAW Administration|Other"]
    Job: [text name="variable_25" default=" "]
    Supervisor:[text name="variable_26" default=""]
13. Sign-in Date: [date name="variable_27" default="mm-dd-yyyy"]

OBJECTIVE:
General: A & O x3. Calm, pleasant and cooperative. Appears well and without s/s of illness.
Musculoskeletal: Ambulated into clinic without difficulty.

ASSESSMENT:
1. B97.2 Coronavirus as the cause of diseases classified elsewhere

PLAN:
1. Employee [select name="Variable_28" value="returned to work full duty.|unable to be returned to work at this time."] Advised to wear a mask through end of day [date name="variable_31" default="mm-dd-yyyy"].
2. RTW 1/2 completed. Copy provided to labor and employee provided 2 copies, 1 for self and 1 for supervisor.
3. COVID testing and/or RTW documentation from provider scanned into the EMR.
4. RTC [select name="Variable_29" value="as needed.|in 1|in 2|in 3|in 4|in 5|in 6"] [select name="Variable_30" value=" |day(s).|week(s).|month(s)."]

As always, you may contact or return to medical for concerns at any time
All dates must be entered as mm-dd-yyyy, if you do not use the drop down calendar. mm/dd/yyyy format will not work. If you don't want to enter dates, leave the field blank and nothing will populate (this is for the vaccines in questions 11 and 12.
SUBJECTIVE:
presents to return to work from COVID-19 illness.1. Last Day Worked:
2. When did your symptoms first appear:
3. What date did you test positive:
4. Have you taken any medication in the last 24 hours for fever:
5. Attending provider: PMD or PCP Name
6. Type of absence:
7. Medical Diagnosis: B97.2 Coronavirus as the cause of diseases classified elsewhere
8. Hospitalized:
9. Provider's written RTW note:
10. Dates coincide with sick leave:
11. Have you received COVID-19 vaccination, primary dose(s):
If yes, what type:
Dates: Leave the next field blank if you have dates or select N/a if no dates.
Have you received COVID-19 vaccination, booster dose(s):
If yes, what type:
Dates: Leave the next field blank if you have dates or select N/a if no dates.
12. Shift:
Department:
Job:
Supervisor:
13. Sign-in Date:

OBJECTIVE:
General: A & O x3. Calm, pleasant and cooperative. Appears well and without s/s of illness.
Musculoskeletal: Ambulated into clinic without difficulty.

ASSESSMENT:
1. B97.2 Coronavirus as the cause of diseases classified elsewhere

PLAN:
1. Employee Advised to wear a mask through end of day .
2. RTW 1/2 completed. Copy provided to labor and employee provided 2 copies, 1 for self and 1 for supervisor.
3. COVID testing and/or RTW documentation from provider scanned into the EMR.
4. RTC

As always, you may contact or return to medical for concerns at any time

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.87, 35 form elements, 180 boilerplate words, 4 text boxes, 10 dates, 17 drop downs, 4 comments, 31 total clicks
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