Preplacement (YYY)

New Hire: [text name="new_hire" default=""]
DOH: [date name="date" default=""]
Work Group: YYY
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|"]
[text name="hepb_titer" default=""]

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 to receive ASAP in order to receive badge|"]
[text name="covid" default=""]

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 stated counseling provided|"]
[text name="tb" default=""]

Respirator Fit Test – [select name="RespFit" value="passed with Prestige Regular; Provided qualitative fit testing using bitrex in compliance with NFPA 1500, NFPA 1404, ANSI Z88.5, ANSI Z88.21992, OSHA CRF 1910.134, and CCR Title 8 Sec. 5144. Respirator training provided on why the respirator is necessary and how improper fit, use or maintenance can compromise its protective effect; limitations and capabilities of the respirator; effective use in emergency situations; how to inspect, put on and remove, use and check the seals; maintenance and storage; and recognition of medical signs and symptoms that may limit or prevent effective use. |did not pass|"]
[text name="respirator_fit_test" 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: YYY
Immunizations:
MMR:
Varicella:
HepB:

HepB Titer:


TdaP:

FLU:
COVID:


TB:


Respirator Fit Test –


Allergies:

Med Hx:

Accommodations:



OHS Clearance:
Needs:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.56, 25 form elements, 26 boilerplate words, 11 text boxes, 1 dates, 13 drop downs, 25 total clicks
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