Preplacement (YYN)

New Hire: [text name="new_hire" default=""]
DOH: [date name="date" default=""]
Work Group: YYN
Immunizations:
MMR: [select name="mmr" value="x2|x3|positive titer|positive titer & x2|x1, titer drawn|x1, vaccine given today, VIS provided, consent obtained|none|titer drawn today"]
Varicella:[select name="varicella" value="x2|x3|positive titer|positive titer & x2|x1, titer drawn|x1, vaccine given today, VIS provided, consent obtained|none|titer drawn today"]
HepB:[select name="hepb" value="x3|x4|x5|x6|none|given today, series started today|"]
[text name="hepb" default=""]
HepB Titer: [select name="HepB" value="drawn @ lab today|positive titer received in past"]

TdaP:[select name="tdap" value="received|given today|"] 
[text name="tdap" default=""]
FLU: [select name="flu" value="received|given today|"]
COVID: [select name="COVID" value="x3|x2, instructed booster deadline was 3/31/22, needs booster ASAP in order to receive badge|"]

TB: [select name="TB" value="drawn @ lab today|received within last 90 days|tested positive in past - has documentation of +tb test, neg chest xray and drs. note stating counseling provided|tested positive in past - has documentation of +tb test, neg chest xray and drs. note stating tx completed|"]
[text name="tb" default=""]


Allergies: [select name="allergies" value="none|yes"]
[text name="allergies" default=""]
Med Hx: [select name="MedHx" value="none|yes"]
[text name="MedHx" default=""]
Accommodations: [select name="Accommodations" value="none|yes"]
[text name="accommodations" default=""]


OHS Clearance: [select name="OHS_clearance" value="pending|cleared"]
Needs:
[text name="needs" default=""]
New Hire:
DOH:
Work Group: YYN
Immunizations:
MMR:
Varicella:
HepB:

HepB Titer:

TdaP:

FLU:
COVID:

TB:



Allergies:

Med Hx:

Accommodations:



OHS Clearance:
Needs:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.62, 21 form elements, 23 boilerplate words, 8 text boxes, 1 dates, 12 drop downs, 21 total clicks
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