[checklist name="variable_1" value="Melanie|Amy|Shevonne|Jen B"]
[date name="DOI" format="mm-dd-yy"]
[text name="Case Number" default="Case#"]
[text name="BCHID#" default="ID#"]
[checklist name="variable_1" value="What/How - Please enter description of injury, do not use abbreviations, try to be as descriptive as possible but be brief|Safety - Please choose mechanism of safety;  if none, choose none|MDPH Sharps - Choose brand/model|OSHA Status - Change to recordable|MDPH Sharps - Enter procedure involved:|Body Fluid - Update with source patient lab results|Accident Type Missing| Source of Injury Missing| Was Exposed Original User - Change to SELF| Was Exposed Original User Change to OTHER PERSON"]
[text name="variable_1" default="Please respond to this e-mail to verify the above chanes have been made"]

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 6 form elements, 3 text boxes, 1 dates, 2 check lists, 18 total clicks
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