AP Chart Review

AP Chart Review 
Job Title: [text name="job_title" default=""]
Work Group: [select name="work_group" value="YYY|NNN|NYN|YYN"]
DOH:[date name="DOH" default=""] [text name="DOH_text" default=""]


Immunizations:
[checklist name="immunizations" value="COVIDx3|Flu UTD|TDAP UTD|PPDx2|IGRA/Quantiferon UTD|HepBx3|HepB titer|MMRx2|VZVx2|MMR titer|VZV titer"]
[text name="immunizations" default=""]

Needs: 
[select name="needs" value="PPD x2 or IGRA w/in 90 days of hire|PPD x2 or IGRA w/in 90 days of hire + respiratory fit test|"]
[text name="needs" default=""]
AP Chart Review
Job Title:
Work Group:
DOH:


Immunizations:



Needs:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 8 form elements, 10 boilerplate words, 4 text boxes, 1 dates, 1 check lists, 2 drop downs, 18 total clicks
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