mjhlifesciences.tfaforms.net Open in urlscan Pro
54.210.107.226  Public Scan

Submitted URL: https://click.email.managedhealthcareexecutive.com/?qs=259bc96498f7fde375b98cfdbea6672407f165351de5172a475226b4ebc71d23d2b75680a94e546ff720eb7c22fe...
Effective URL: https://mjhlifesciences.tfaforms.net/59?tfa_1235=Marilu&tfa_6=Minor&tfa_1233=marilu.minor@providence.org
Submission: On May 05 via api from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://mjhlifesciences.tfaforms.net/api_v2/workflow/processor

<form method="post" action="https://mjhlifesciences.tfaforms.net/api_v2/workflow/processor" class="hintsBelow labelsAbove" id="59" role="form">
  <input type="hidden" id="tfa_1213" name="tfa_1213" value="Chief Healthcare Executive Web Registration" class=""><input type="hidden" id="tfa_1215" name="tfa_1215" value="https://www.chiefhealthcareexecutive.com/" class="">
  <div class="oneField field-container-D     wf-acl-hidden" id="tfa_2-D">
    <label id="tfa_2-L" class="label preField " for="tfa_2">Promo Code</label><br>
    <div class="inputWrapper"><input type="text" id="tfa_2" name="tfa_2" value="" title="Promo Code" class=""></div>
  </div>
  <div class="oneField field-container-D     wf-acl-hidden" id="tfa_1-D">
    <label id="tfa_1-L" class="label preField " for="tfa_1">anonymousid</label><br>
    <div class="inputWrapper"><input type="text" id="tfa_1" name="tfa_1" value="" title="anonymousid" class=""></div>
  </div>
  <div class="oneField field-container-D    " id="tfa_1233-D">
    <label id="tfa_1233-L" class="label preField reqMark" for="tfa_1233">Email Address</label><br>
    <div class="inputWrapper"><input aria-required="true" type="text" id="tfa_1233" name="tfa_1233" value="marilu.minor@providence.org" title="Email Address" class="validate-email required"></div>
  </div>
  <div class="oneField field-container-D    " id="tfa_1235-D">
    <label id="tfa_1235-L" class="label preField reqMark" for="tfa_1235">First Name</label><br>
    <div class="inputWrapper"><input aria-required="true" type="text" id="tfa_1235" name="tfa_1235" value="Marilu" title="First Name" class="required"></div>
  </div>
  <div class="oneField field-container-D    " id="tfa_6-D">
    <label id="tfa_6-L" class="label preField reqMark" for="tfa_6">Last Name</label><br>
    <div class="inputWrapper"><input aria-required="true" type="text" id="tfa_6" name="tfa_6" value="Minor" title="Last Name" class="required"></div>
  </div>
  <div class="oneField field-container-D    " id="tfa_1229-D">
    <label id="tfa_1229-L" class="label preField " for="tfa_1229">Title</label><br>
    <div class="inputWrapper"><input type="text" id="tfa_1229" name="tfa_1229" value="" title="Title" class=""></div>
  </div>
  <div class="oneField field-container-D    " id="tfa_4-D">
    <label id="tfa_4-L" class="label preField reqMark" for="tfa_4">Company Name</label><br>
    <div class="inputWrapper"><input aria-required="true" type="text" id="tfa_4" name="tfa_4" value="" title="Company Name" class="required"></div>
  </div>
  <div class="oneField field-container-D    " id="tfa_8-D">
    <label id="tfa_8-L" class="label preField reqMark" for="tfa_8">Country</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_8" name="tfa_8" title="Country" class="required">
        <option value="">Please select...</option>
        <option value="tfa_9" id="tfa_9" class="">Afghanistan</option>
        <option value="tfa_10" id="tfa_10" class="">Albania</option>
        <option value="tfa_11" id="tfa_11" class="">Algeria</option>
        <option value="tfa_12" id="tfa_12" class="">American Samoa</option>
        <option value="tfa_13" id="tfa_13" class="">Andorra</option>
        <option value="tfa_14" id="tfa_14" class="">Angola</option>
        <option value="tfa_15" id="tfa_15" class="">Anguilla</option>
        <option value="tfa_16" id="tfa_16" class="">Antarctica</option>
        <option value="tfa_17" id="tfa_17" class="">Antigua and Barbuda</option>
        <option value="tfa_18" id="tfa_18" class="">Argentina</option>
        <option value="tfa_19" id="tfa_19" class="">Armenia</option>
        <option value="tfa_20" id="tfa_20" class="">Aruba</option>
        <option value="tfa_21" id="tfa_21" class="">Australia</option>
        <option value="tfa_22" id="tfa_22" class="">Austria</option>
        <option value="tfa_23" id="tfa_23" class="">Azerbaijan</option>
        <option value="tfa_24" id="tfa_24" class="">Bahamas</option>
        <option value="tfa_25" id="tfa_25" class="">Bahrain</option>
        <option value="tfa_26" id="tfa_26" class="">Bangladesh</option>
        <option value="tfa_27" id="tfa_27" class="">Barbados</option>
        <option value="tfa_28" id="tfa_28" class="">Belarus</option>
        <option value="tfa_29" id="tfa_29" class="">Belgium</option>
        <option value="tfa_30" id="tfa_30" class="">Belize</option>
        <option value="tfa_31" id="tfa_31" class="">Benin</option>
        <option value="tfa_32" id="tfa_32" class="">Bermuda</option>
        <option value="tfa_33" id="tfa_33" class="">Bhutan</option>
        <option value="tfa_34" id="tfa_34" class="">Bolivia</option>
        <option value="tfa_35" id="tfa_35" class="">Bosnia and Herzegovina</option>
        <option value="tfa_36" id="tfa_36" class="">Botswana</option>
        <option value="tfa_37" id="tfa_37" class="">Bouvet Island</option>
        <option value="tfa_38" id="tfa_38" class="">Brazil</option>
        <option value="tfa_39" id="tfa_39" class="">British Indian Ocean Territory</option>
        <option value="tfa_40" id="tfa_40" class="">Brunei</option>
        <option value="tfa_41" id="tfa_41" class="">Bulgaria</option>
        <option value="tfa_42" id="tfa_42" class="">Burkina Faso</option>
        <option value="tfa_43" id="tfa_43" class="">Burundi</option>
        <option value="tfa_44" id="tfa_44" class="">Cambodia</option>
        <option value="tfa_45" id="tfa_45" class="">Cameroon</option>
        <option value="tfa_46" id="tfa_46" class="">Canada</option>
        <option value="tfa_47" id="tfa_47" class="">Cape Verde</option>
        <option value="tfa_48" id="tfa_48" class="">Cayman Islands</option>
        <option value="tfa_49" id="tfa_49" class="">Central African Republic</option>
        <option value="tfa_50" id="tfa_50" class="">Chad</option>
        <option value="tfa_51" id="tfa_51" class="">Chile</option>
        <option value="tfa_52" id="tfa_52" class="">China</option>
        <option value="tfa_53" id="tfa_53" class="">Christmas Island</option>
        <option value="tfa_54" id="tfa_54" class="">Cocos ( Keeling ) Islands</option>
        <option value="tfa_55" id="tfa_55" class="">Colombia</option>
        <option value="tfa_56" id="tfa_56" class="">Comoros</option>
        <option value="tfa_57" id="tfa_57" class="">Congo</option>
        <option value="tfa_58" id="tfa_58" class="">Cook Islands</option>
        <option value="tfa_59" id="tfa_59" class="">Costa Rica</option>
        <option value="tfa_60" id="tfa_60" class="">Côte d ' Ivoire</option>
        <option value="tfa_61" id="tfa_61" class="">Croatia ( Hrvatska )</option>
        <option value="tfa_62" id="tfa_62" class="">Cuba</option>
        <option value="tfa_63" id="tfa_63" class="">Cyprus</option>
        <option value="tfa_64" id="tfa_64" class="">Czech Republic</option>
        <option value="tfa_65" id="tfa_65" class="">Congo ( DRC )</option>
        <option value="tfa_66" id="tfa_66" class="">Denmark</option>
        <option value="tfa_67" id="tfa_67" class="">Djibouti</option>
        <option value="tfa_68" id="tfa_68" class="">Dominica</option>
        <option value="tfa_69" id="tfa_69" class="">Dominican Republic</option>
        <option value="tfa_70" id="tfa_70" class="">East Timor</option>
        <option value="tfa_71" id="tfa_71" class="">Ecuador</option>
        <option value="tfa_72" id="tfa_72" class="">Egypt</option>
        <option value="tfa_73" id="tfa_73" class="">El Salvador</option>
        <option value="tfa_74" id="tfa_74" class="">Equatorial Guinea</option>
        <option value="tfa_75" id="tfa_75" class="">Eritrea</option>
        <option value="tfa_76" id="tfa_76" class="">Estonia</option>
        <option value="tfa_77" id="tfa_77" class="">Ethiopia</option>
        <option value="tfa_78" id="tfa_78" class="">Falkland Islands ( Islas Malvinas )</option>
        <option value="tfa_79" id="tfa_79" class="">Faroe Islands</option>
        <option value="tfa_80" id="tfa_80" class="">Fiji Islands</option>
        <option value="tfa_81" id="tfa_81" class="">Finland</option>
        <option value="tfa_82" id="tfa_82" class="">France</option>
        <option value="tfa_83" id="tfa_83" class="">French Guiana</option>
        <option value="tfa_84" id="tfa_84" class="">French Polynesia</option>
        <option value="tfa_85" id="tfa_85" class="">French Southern and Antarctic Lands</option>
        <option value="tfa_86" id="tfa_86" class="">Gabon</option>
        <option value="tfa_87" id="tfa_87" class="">Gambia</option>
        <option value="tfa_88" id="tfa_88" class="">Georgia</option>
        <option value="tfa_89" id="tfa_89" class="">Germany</option>
        <option value="tfa_90" id="tfa_90" class="">Ghana</option>
        <option value="tfa_91" id="tfa_91" class="">Gibraltar</option>
        <option value="tfa_92" id="tfa_92" class="">Greece</option>
        <option value="tfa_93" id="tfa_93" class="">Greenland</option>
        <option value="tfa_94" id="tfa_94" class="">Grenada</option>
        <option value="tfa_95" id="tfa_95" class="">Guadeloupe</option>
        <option value="tfa_96" id="tfa_96" class="">Guam</option>
        <option value="tfa_97" id="tfa_97" class="">Guatemala</option>
        <option value="tfa_98" id="tfa_98" class="">Guinea</option>
        <option value="tfa_99" id="tfa_99" class="">Guinea-Bissau</option>
        <option value="tfa_100" id="tfa_100" class="">Guyana</option>
        <option value="tfa_101" id="tfa_101" class="">Haiti</option>
        <option value="tfa_102" id="tfa_102" class="">Heard Island and McDonald Islands</option>
        <option value="tfa_103" id="tfa_103" class="">Honduras</option>
        <option value="tfa_104" id="tfa_104" class="">Hong Kong SAR</option>
        <option value="tfa_105" id="tfa_105" class="">Hungary</option>
        <option value="tfa_106" id="tfa_106" class="">Iceland</option>
        <option value="tfa_107" id="tfa_107" class="">India</option>
        <option value="tfa_108" id="tfa_108" class="">Indonesia</option>
        <option value="tfa_109" id="tfa_109" class="">Iran</option>
        <option value="tfa_110" id="tfa_110" class="">Iraq</option>
        <option value="tfa_111" id="tfa_111" class="">Ireland</option>
        <option value="tfa_112" id="tfa_112" class="">Israel</option>
        <option value="tfa_113" id="tfa_113" class="">Italy</option>
        <option value="tfa_114" id="tfa_114" class="">Jamaica</option>
        <option value="tfa_115" id="tfa_115" class="">Japan</option>
        <option value="tfa_116" id="tfa_116" class="">Jordan</option>
        <option value="tfa_117" id="tfa_117" class="">Kazakhstan</option>
        <option value="tfa_118" id="tfa_118" class="">Kenya</option>
        <option value="tfa_119" id="tfa_119" class="">Kiribati</option>
        <option value="tfa_120" id="tfa_120" class="">Korea</option>
        <option value="tfa_121" id="tfa_121" class="">Kuwait</option>
        <option value="tfa_122" id="tfa_122" class="">Kyrgyzstan</option>
        <option value="tfa_123" id="tfa_123" class="">Laos</option>
        <option value="tfa_124" id="tfa_124" class="">Latvia</option>
        <option value="tfa_125" id="tfa_125" class="">Lebanon</option>
        <option value="tfa_126" id="tfa_126" class="">Lesotho</option>
        <option value="tfa_127" id="tfa_127" class="">Liberia</option>
        <option value="tfa_128" id="tfa_128" class="">Libya</option>
        <option value="tfa_129" id="tfa_129" class="">Liechtenstein</option>
        <option value="tfa_130" id="tfa_130" class="">Lithuania</option>
        <option value="tfa_131" id="tfa_131" class="">Luxembourg</option>
        <option value="tfa_132" id="tfa_132" class="">Macao SAR</option>
        <option value="tfa_133" id="tfa_133" class="">Macedonia, Former Yugoslav Republic of</option>
        <option value="tfa_134" id="tfa_134" class="">Madagascar</option>
        <option value="tfa_135" id="tfa_135" class="">Malawi</option>
        <option value="tfa_136" id="tfa_136" class="">Malaysia</option>
        <option value="tfa_137" id="tfa_137" class="">Maldives</option>
        <option value="tfa_138" id="tfa_138" class="">Mali</option>
        <option value="tfa_139" id="tfa_139" class="">Malta</option>
        <option value="tfa_140" id="tfa_140" class="">Marshall Islands</option>
        <option value="tfa_141" id="tfa_141" class="">Martinique</option>
        <option value="tfa_142" id="tfa_142" class="">Mauritania</option>
        <option value="tfa_143" id="tfa_143" class="">Mauritius</option>
        <option value="tfa_144" id="tfa_144" class="">Mayotte</option>
        <option value="tfa_145" id="tfa_145" class="">Mexico</option>
        <option value="tfa_146" id="tfa_146" class="">Micronesia</option>
        <option value="tfa_147" id="tfa_147" class="">Moldova</option>
        <option value="tfa_148" id="tfa_148" class="">Monaco</option>
        <option value="tfa_149" id="tfa_149" class="">Mongolia</option>
        <option value="tfa_150" id="tfa_150" class="">Montserrat</option>
        <option value="tfa_151" id="tfa_151" class="">Morocco</option>
        <option value="tfa_152" id="tfa_152" class="">Mozambique</option>
        <option value="tfa_153" id="tfa_153" class="">Myanmar</option>
        <option value="tfa_154" id="tfa_154" class="">Namibia</option>
        <option value="tfa_155" id="tfa_155" class="">Nauru</option>
        <option value="tfa_156" id="tfa_156" class="">Nepal</option>
        <option value="tfa_157" id="tfa_157" class="">Netherlands</option>
        <option value="tfa_158" id="tfa_158" class="">Netherlands Antilles</option>
        <option value="tfa_159" id="tfa_159" class="">New Caledonia</option>
        <option value="tfa_160" id="tfa_160" class="">New Zealand</option>
        <option value="tfa_161" id="tfa_161" class="">Nicaragua</option>
        <option value="tfa_162" id="tfa_162" class="">Niger</option>
        <option value="tfa_163" id="tfa_163" class="">Nigeria</option>
        <option value="tfa_164" id="tfa_164" class="">Niue</option>
        <option value="tfa_165" id="tfa_165" class="">Norfolk Island</option>
        <option value="tfa_166" id="tfa_166" class="">North Korea</option>
        <option value="tfa_167" id="tfa_167" class="">Northern Mariana Islands</option>
        <option value="tfa_168" id="tfa_168" class="">Norway</option>
        <option value="tfa_169" id="tfa_169" class="">Oman</option>
        <option value="tfa_170" id="tfa_170" class="">Pakistan</option>
        <option value="tfa_171" id="tfa_171" class="">Palau</option>
        <option value="tfa_172" id="tfa_172" class="">Panama</option>
        <option value="tfa_173" id="tfa_173" class="">Papua New Guinea</option>
        <option value="tfa_174" id="tfa_174" class="">Paraguay</option>
        <option value="tfa_175" id="tfa_175" class="">Peru</option>
        <option value="tfa_176" id="tfa_176" class="">Philippines</option>
        <option value="tfa_177" id="tfa_177" class="">Pitcairn Islands</option>
        <option value="tfa_178" id="tfa_178" class="">Poland</option>
        <option value="tfa_179" id="tfa_179" class="">Portugal</option>
        <option value="tfa_180" id="tfa_180" class="">Puerto Rico</option>
        <option value="tfa_181" id="tfa_181" class="">Qatar</option>
        <option value="tfa_182" id="tfa_182" class="">Reunion</option>
        <option value="tfa_183" id="tfa_183" class="">Romania</option>
        <option value="tfa_184" id="tfa_184" class="">Russia</option>
        <option value="tfa_185" id="tfa_185" class="">Rwanda</option>
        <option value="tfa_186" id="tfa_186" class="">Samoa</option>
        <option value="tfa_187" id="tfa_187" class="">San Marino</option>
        <option value="tfa_188" id="tfa_188" class="">São Tomé and Prìncipe</option>
        <option value="tfa_189" id="tfa_189" class="">Saudi Arabia</option>
        <option value="tfa_190" id="tfa_190" class="">Senegal</option>
        <option value="tfa_191" id="tfa_191" class="">Serbia and Montenegro</option>
        <option value="tfa_192" id="tfa_192" class="">Seychelles</option>
        <option value="tfa_193" id="tfa_193" class="">Sierra Leone</option>
        <option value="tfa_194" id="tfa_194" class="">Singapore</option>
        <option value="tfa_195" id="tfa_195" class="">Slovakia</option>
        <option value="tfa_196" id="tfa_196" class="">Slovenia</option>
        <option value="tfa_197" id="tfa_197" class="">Solomon Islands</option>
        <option value="tfa_198" id="tfa_198" class="">Somalia</option>
        <option value="tfa_199" id="tfa_199" class="">South Africa</option>
        <option value="tfa_200" id="tfa_200" class="">South Georgia and the South Sandwich Islands</option>
        <option value="tfa_201" id="tfa_201" class="">Spain</option>
        <option value="tfa_202" id="tfa_202" class="">Sri Lanka</option>
        <option value="tfa_203" id="tfa_203" class="">St. Helena</option>
        <option value="tfa_204" id="tfa_204" class="">St. Kitts and Nevis</option>
        <option value="tfa_205" id="tfa_205" class="">St. Lucia</option>
        <option value="tfa_206" id="tfa_206" class="">St. Pierre and Miquelon</option>
        <option value="tfa_207" id="tfa_207" class="">St. Vincent and the Grenadines</option>
        <option value="tfa_208" id="tfa_208" class="">Sudan</option>
        <option value="tfa_209" id="tfa_209" class="">Suriname</option>
        <option value="tfa_210" id="tfa_210" class="">Svalbard and Jan Mayen</option>
        <option value="tfa_211" id="tfa_211" class="">Swaziland</option>
        <option value="tfa_212" id="tfa_212" class="">Sweden</option>
        <option value="tfa_213" id="tfa_213" class="">Switzerland</option>
        <option value="tfa_214" id="tfa_214" class="">Syria</option>
        <option value="tfa_215" id="tfa_215" class="">Taiwan</option>
        <option value="tfa_216" id="tfa_216" class="">Tajikistan</option>
        <option value="tfa_217" id="tfa_217" class="">Tanzania</option>
        <option value="tfa_218" id="tfa_218" class="">Thailand</option>
        <option value="tfa_219" id="tfa_219" class="">Togo</option>
        <option value="tfa_220" id="tfa_220" class="">Tokelau</option>
        <option value="tfa_221" id="tfa_221" class="">Tonga</option>
        <option value="tfa_222" id="tfa_222" class="">Trinidad and Tobago</option>
        <option value="tfa_223" id="tfa_223" class="">Tunisia</option>
        <option value="tfa_224" id="tfa_224" class="">Turkey</option>
        <option value="tfa_225" id="tfa_225" class="">Turkmenistan</option>
        <option value="tfa_226" id="tfa_226" class="">Turks and Caicos Islands</option>
        <option value="tfa_227" id="tfa_227" class="">Tuvalu</option>
        <option value="tfa_228" id="tfa_228" class="">Uganda</option>
        <option value="tfa_229" id="tfa_229" class="">Ukraine</option>
        <option value="tfa_230" id="tfa_230" class="">United Arab Emirates</option>
        <option value="tfa_231" id="tfa_231" class="">United Kingdom</option>
        <option value="tfa_232" id="tfa_232" data-conditionals="#tfa_246,#tfa_361" class="">United States</option>
        <option value="tfa_233" id="tfa_233" class="">United States Minor Outlying Islands</option>
        <option value="tfa_234" id="tfa_234" class="">Uruguay</option>
        <option value="tfa_235" id="tfa_235" class="">Uzbekistan</option>
        <option value="tfa_236" id="tfa_236" class="">Vanuatu</option>
        <option value="tfa_237" id="tfa_237" class="">Vatican City</option>
        <option value="tfa_238" id="tfa_238" class="">Venezuela</option>
        <option value="tfa_239" id="tfa_239" class="">Viet Nam</option>
        <option value="tfa_240" id="tfa_240" class="">Virgin Islands ( British )</option>
        <option value="tfa_241" id="tfa_241" class="">Virgin Islands</option>
        <option value="tfa_242" id="tfa_242" class="">Wallis and Futuna</option>
        <option value="tfa_243" id="tfa_243" class="">Yemen</option>
        <option value="tfa_244" id="tfa_244" class="">Zambia</option>
        <option value="tfa_245" id="tfa_245" class="">Zimbabwe</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_246-D">
    <label id="tfa_246-L" class="label preField reqMark" for="tfa_246">State</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_246" name="tfa_246" data-filter-control="#tfa_246" data-filter-dependent="#tfa_246" data-condition="`#tfa_232`" title="State" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_247" id="tfa_247" class="">Alabama</option>
        <option value="tfa_248" id="tfa_248" class="">Alaska</option>
        <option value="tfa_249" id="tfa_249" class="">Arizona</option>
        <option value="tfa_250" id="tfa_250" class="">Arkansas</option>
        <option value="tfa_251" id="tfa_251" class="">California</option>
        <option value="tfa_252" id="tfa_252" class="">Colorado</option>
        <option value="tfa_253" id="tfa_253" class="">Connecticut</option>
        <option value="tfa_254" id="tfa_254" class="">Delaware</option>
        <option value="tfa_255" id="tfa_255" class="">District Of Columbia</option>
        <option value="tfa_256" id="tfa_256" class="">Florida</option>
        <option value="tfa_257" id="tfa_257" class="">Georgia</option>
        <option value="tfa_258" id="tfa_258" class="">Hawaii</option>
        <option value="tfa_259" id="tfa_259" class="">Idaho</option>
        <option value="tfa_260" id="tfa_260" class="">Illinois</option>
        <option value="tfa_261" id="tfa_261" class="">Indiana</option>
        <option value="tfa_262" id="tfa_262" class="">Iowa</option>
        <option value="tfa_263" id="tfa_263" class="">Kansas</option>
        <option value="tfa_264" id="tfa_264" class="">Kentucky</option>
        <option value="tfa_265" id="tfa_265" class="">Louisiana</option>
        <option value="tfa_266" id="tfa_266" class="">Maine</option>
        <option value="tfa_267" id="tfa_267" class="">Maryland</option>
        <option value="tfa_268" id="tfa_268" class="">Massachusetts</option>
        <option value="tfa_269" id="tfa_269" class="">Michigan</option>
        <option value="tfa_270" id="tfa_270" class="">Minnesota</option>
        <option value="tfa_271" id="tfa_271" class="">Mississippi</option>
        <option value="tfa_272" id="tfa_272" class="">Missouri</option>
        <option value="tfa_273" id="tfa_273" class="">Montana</option>
        <option value="tfa_274" id="tfa_274" class="">Nebraska</option>
        <option value="tfa_275" id="tfa_275" class="">Nevada</option>
        <option value="tfa_276" id="tfa_276" class="">New Hampshire</option>
        <option value="tfa_277" id="tfa_277" class="">New Jersey</option>
        <option value="tfa_278" id="tfa_278" class="">New Mexico</option>
        <option value="tfa_279" id="tfa_279" class="">New York</option>
        <option value="tfa_280" id="tfa_280" class="">North Carolina</option>
        <option value="tfa_281" id="tfa_281" class="">North Dakota</option>
        <option value="tfa_282" id="tfa_282" class="">Ohio</option>
        <option value="tfa_283" id="tfa_283" class="">Oklahoma</option>
        <option value="tfa_284" id="tfa_284" class="">Oregon</option>
        <option value="tfa_285" id="tfa_285" class="">Pennsylvania</option>
        <option value="tfa_286" id="tfa_286" class="">Rhode Island</option>
        <option value="tfa_287" id="tfa_287" class="">South Carolina</option>
        <option value="tfa_288" id="tfa_288" class="">South Dakota</option>
        <option value="tfa_289" id="tfa_289" class="">Tennessee</option>
        <option value="tfa_290" id="tfa_290" class="">Texas</option>
        <option value="tfa_291" id="tfa_291" class="">Utah</option>
        <option value="tfa_292" id="tfa_292" class="">Vermont</option>
        <option value="tfa_293" id="tfa_293" class="">Virginia</option>
        <option value="tfa_294" id="tfa_294" class="">Washington</option>
        <option value="tfa_295" id="tfa_295" class="">West Virginia</option>
        <option value="tfa_296" id="tfa_296" class="">Wisconsin</option>
        <option value="tfa_297" id="tfa_297" class="">Wyoming</option>
        <option value="tfa_298" id="tfa_298" class="">Puerto Rico</option>
        <option value="tfa_299" id="tfa_299" class="">Virgin Island</option>
        <option value="tfa_300" id="tfa_300" class="">Northern Mariana Islands</option>
        <option value="tfa_301" id="tfa_301" class="">Guam</option>
        <option value="tfa_302" id="tfa_302" class="">American Samoa</option>
        <option value="tfa_303" id="tfa_303" class="">Palau</option>
        <optgroup id="tfa_304" label="Alabama" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_305" label="Alaska" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_306" label="Arizona" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_307" label="Arkansas" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_308" label="California" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_309" label="Colorado" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_310" label="Connecticut" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_311" label="Delaware" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_312" label="District Of Columbia" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_313" label="Florida" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_314" label="Georgia" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_315" label="Hawaii" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_316" label="Idaho" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_317" label="Illinois" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_318" label="Indiana" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_319" label="Iowa" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_320" label="Kansas" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_321" label="Kentucky" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_322" label="Louisiana" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_323" label="Maine" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_324" label="Maryland" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_325" label="Massachusetts" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_326" label="Michigan" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_327" label="Minnesota" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_328" label="Mississippi" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_329" label="Missouri" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_330" label="Montana" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_331" label="Nebraska" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_332" label="Nevada" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_333" label="New Hampshire" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_334" label="New Jersey" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_335" label="New Mexico" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_336" label="New York" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_337" label="North Carolina" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_338" label="North Dakota" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_339" label="Ohio" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_340" label="Oklahoma" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_341" label="Oregon" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_342" label="Pennsylvania" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_343" label="Rhode Island" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_344" label="South Carolina" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_345" label="South Dakota" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_346" label="Tennessee" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_347" label="Texas" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_348" label="Utah" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_349" label="Vermont" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_350" label="Virginia" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_351" label="Washington" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_352" label="West Virginia" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_353" label="Wisconsin" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_354" label="Wyoming" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_355" label="Puerto Rico" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_356" label="Virgin Island" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_357" label="Northern Mariana Islands" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_358" label="Guam" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_359" label="American Samoa" class="choiceGroup" disabled="" style="display: none;"></optgroup>
        <optgroup id="tfa_360" label="Palau" class="choiceGroup" disabled="" style="display: none;"></optgroup>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_361-D">
    <label id="tfa_361-L" class="label preField " for="tfa_361">Work Zip Code</label><br>
    <div class="inputWrapper"><input type="text" id="tfa_361" name="tfa_361" value="" min="00001" max="99999" data-condition="`#tfa_232`" title="Work Zip Code" class="validate-integer" disabled=""></div>
  </div>
  <div class="oneField field-container-D    " id="tfa_362-D">
    <label id="tfa_362-L" class="label preField " for="tfa_362">Phone</label><br>
    <div class="inputWrapper">
      <div><input type="text" id="tfa_362" name="tfa_362" value="" maxlength="11" title="Phone" class="validate-integer">
        <div class="lengthIndicator" aria-live="assertive" style="display: none; left: 306px;">11 characters left.</div>
      </div>
    </div>
  </div>
  <div class="oneField field-container-D    " id="tfa_372-D">
    <label id="tfa_372-L" class="label preField reqMark" for="tfa_372">Occupation</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_372" name="tfa_372" title="Occupation" class="required">
        <option value="">Please select...</option>
        <option value="tfa_373" id="tfa_373" data-conditionals="#tfa_657,#tfa_1130,#tfa_1128,#tfa_1126" class="">Physician</option>
        <option value="tfa_374" id="tfa_374" data-conditionals="#tfa_657,#tfa_1130,#tfa_1128,#tfa_1126" class="">Physician Assistant</option>
        <option value="tfa_375" id="tfa_375" data-conditionals="#tfa_403,#tfa_657,#tfa_1126" class="">Nurse/Advanced Practice Nurse</option>
        <option value="tfa_376" id="tfa_376" data-conditionals="#tfa_657,#tfa_1130,#tfa_1126" class="">Medical Student</option>
        <option value="tfa_377" id="tfa_377" data-conditionals="#tfa_657,#tfa_1126" class="">Resident/Fellow</option>
        <option value="tfa_378" id="tfa_378" data-conditionals="#tfa_596,#tfa_1126" class="">Pharmacy Professional </option>
        <option value="tfa_379" id="tfa_379" data-conditionals="#tfa_617,#tfa_902,#tfa_1128" class="">Optometrist/Optician/Ophthalmic Technician</option>
        <option value="tfa_380" id="tfa_380" data-conditionals="#tfa_611,#tfa_629,#tfa_1130,#tfa_1128,#tfa_1126" class="">Psychiatry/Psychology Professional</option>
        <option value="tfa_381" id="tfa_381" data-conditionals="#tfa_421,#tfa_569,#tfa_1130,#tfa_1128,#tfa_1126,#tfa_550" class="">Dental/Oral Health Provider/DSO</option>
        <option value="tfa_382" id="tfa_382" data-conditionals="#tfa_465,#tfa_484" class="">Infection Control</option>
        <option value="tfa_383" id="tfa_383" data-conditionals="#tfa_736" class="">Health/Business Administration</option>
        <option value="tfa_384" id="tfa_384" data-conditionals="#tfa_800" class="">Other Health Care Provider</option>
        <option value="tfa_392" id="tfa_392" data-conditionals="#tfa_363,#tfa_982" class="">Patient</option>
        <option value="tfa_393" id="tfa_393" data-conditionals="#tfa_657" class="">Medical Science Liasion</option>
        <option value="tfa_394" id="tfa_394" data-conditionals="#tfa_982" class="">Media/Press</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_363-D">
    <label id="tfa_363-L" class="label preField reqMark" for="tfa_363">Patient Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_363" name="tfa_363" data-condition="`#tfa_392`" title="Patient Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_388" id="tfa_388" class="">Patient </option>
        <option value="tfa_389" id="tfa_389" class="">Caregiver </option>
        <option value="tfa_390" id="tfa_390" class="">Advocate </option>
        <option value="tfa_391" id="tfa_391" class="">Other</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_403-D">
    <label id="tfa_403-L" class="label preField reqMark" for="tfa_403">Nurse/Advanced Practice Nurse Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_403" name="tfa_403" data-condition="`#tfa_375`" title="Nurse/Advanced Practice Nurse Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_404" id="tfa_404" class="">Clinical Nurse Specialist</option>
        <option value="tfa_405" id="tfa_405" class="">Licensed Practical Nurse (LPN/LVN)</option>
        <option value="tfa_406" id="tfa_406" class=""> Nurse Anethesist</option>
        <option value="tfa_407" id="tfa_407" class="">Nurse Midwife</option>
        <option value="tfa_408" id="tfa_408" data-conditionals="#tfa_1130,#tfa_1128" class="">Nurse Practicioner (NP)</option>
        <option value="tfa_409" id="tfa_409" class="">Nursing Student</option>
        <option value="tfa_410" id="tfa_410" class="">Registered Nurse (RN)</option>
        <option value="tfa_411" id="tfa_411" class="">Director of Nursing</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_421-D">
    <label id="tfa_421-L" class="label preField reqMark" for="tfa_421">Dental Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_421" name="tfa_421" data-condition="`#tfa_381`" title="Dental Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_422" id="tfa_422" class="">Dental Anesthesiologist</option>
        <option value="tfa_423" id="tfa_423" class="">Dentist</option>
        <option value="tfa_424" id="tfa_424" class="">Dentist, Owner/President</option>
        <option value="tfa_425" id="tfa_425" class="">Dental Assistant</option>
        <option value="tfa_426" id="tfa_426" class="">Dental Hygienist</option>
        <option value="tfa_427" id="tfa_427" class="">Dental Student</option>
        <option value="tfa_428" id="tfa_428" class="">Dental Technician</option>
        <option value="tfa_429" id="tfa_429" data-conditionals="#tfa_514" class="">Dental Support Organization (DSO)</option>
        <option value="tfa_430" id="tfa_430" class="">Director/Instructor</option>
        <option value="tfa_431" id="tfa_431" class="">Endodontist</option>
        <option value="tfa_432" id="tfa_432" class="">Office Manager/Administrator</option>
        <option value="tfa_433" id="tfa_433" class="">Oral Pathologist</option>
        <option value="tfa_434" id="tfa_434" class="">Orthodontist</option>
        <option value="tfa_435" id="tfa_435" class="">Other</option>
        <option value="tfa_436" id="tfa_436" class="">Owner or Manager of Dental Labs</option>
        <option value="tfa_437" id="tfa_437" class="">Pediatric Dentist</option>
        <option value="tfa_438" id="tfa_438" class="">Periodontist</option>
        <option value="tfa_439" id="tfa_439" class="">Prosthodontist</option>
        <option value="tfa_440" id="tfa_440" class="">Sales Representative</option>
        <option value="tfa_441" id="tfa_441" class="">Surgeon, Cosmetic</option>
        <option value="tfa_442" id="tfa_442" class="">Surgeon, Oral &amp; Maxillofacial</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_465-D">
    <label id="tfa_465-L" class="label preField reqMark" for="tfa_465">Infection Control Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_465" name="tfa_465" data-condition="`#tfa_382`" title="Infection Control Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_466" id="tfa_466" class="">Infection Preventionist (IP)</option>
        <option value="tfa_467" id="tfa_467" class="">Infection Control Practicioner (ICP)</option>
        <option value="tfa_468" id="tfa_468" class="">C-Suite</option>
        <option value="tfa_469" id="tfa_469" class="">Chief Nursing Officer/Director of Nursing/Director of Infection Prevention</option>
        <option value="tfa_470" id="tfa_470" class="">NP/RN/Nurse</option>
        <option value="tfa_471" id="tfa_471" class="">Administrator/President/VP</option>
        <option value="tfa_472" id="tfa_472" class="">Manager/Director/Department Head</option>
        <option value="tfa_473" id="tfa_473" class="">Assistant Manager/Director</option>
        <option value="tfa_474" id="tfa_474" class="">Supervisor/Coordinator</option>
        <option value="tfa_475" id="tfa_475" class="">Purchasing/Procurement/Supply Chain</option>
        <option value="tfa_476" id="tfa_476" class="">Technician</option>
        <option value="tfa_477" id="tfa_477" class="">Physician</option>
        <option value="tfa_478" id="tfa_478" class="">Patient Safety Officer/Supervisor/Specialist</option>
        <option value="tfa_479" id="tfa_479" class="">Risk Manager</option>
        <option value="tfa_480" id="tfa_480" class="">Quality Improvement Supervisor/Specialist</option>
        <option value="tfa_481" id="tfa_481" class="">Consultant</option>
        <option value="tfa_482" id="tfa_482" data-conditionals="#tfa_483" class="">Other (please specify)</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_483-D">
    <label id="tfa_483-L" class="label preField reqMark" for="tfa_483">Infection Control Role: Other (please specify)</label><br>
    <div class="inputWrapper"><input aria-required="true" type="text" id="tfa_483" name="tfa_483" value="" data-condition="`#tfa_482`" title="Infection Control Role: Other (please specify)" class="required" disabled=""></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_484-D" role="group" aria-labelledby="tfa_484-L" data-tfa-labelledby="-L tfa_484-L" aria-required="true">
    <label id="tfa_484-L" class="label preField reqMark" aria-label="Infection Control Area of Focus &nbsp; required">Infection Control Area of Focus</label><br>
    <div class="inputWrapper"><span id="tfa_484" class="choices vertical required" aria-required="true" data-condition="`#tfa_382`"><span class="oneChoice"><input type="checkbox" value="tfa_485" class="" id="tfa_485" name="tfa_485"
            aria-labelledby="tfa_485-L" data-tfa-labelledby="tfa_484-L tfa_485-L" disabled=""><label class="label postField" id="tfa_485-L" for="tfa_485"><span class="input-checkbox-faux"></span>Infection Control</label></span><span
          class="oneChoice"><input type="checkbox" value="tfa_486" class="" id="tfa_486" name="tfa_486" aria-labelledby="tfa_486-L" data-tfa-labelledby="tfa_484-L tfa_486-L" disabled=""><label class="label postField" id="tfa_486-L"
            for="tfa_486"><span class="input-checkbox-faux"></span>OR/Surgery</label></span><span class="oneChoice"><input type="checkbox" value="tfa_487" class="" id="tfa_487" name="tfa_487" aria-labelledby="tfa_487-L"
            data-tfa-labelledby="tfa_484-L tfa_487-L" disabled=""><label class="label postField" id="tfa_487-L" for="tfa_487"><span class="input-checkbox-faux"></span>Sterile Processing/Cs/Spd</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_488" class="" id="tfa_488" name="tfa_488" aria-labelledby="tfa_488-L" data-tfa-labelledby="tfa_484-L tfa_488-L" disabled=""><label class="label postField" id="tfa_488-L" for="tfa_488"><span
              class="input-checkbox-faux"></span>Nursing</label></span><span class="oneChoice"><input type="checkbox" value="tfa_489" class="" id="tfa_489" name="tfa_489" aria-labelledby="tfa_489-L" data-tfa-labelledby="tfa_484-L tfa_489-L"
            disabled=""><label class="label postField" id="tfa_489-L" for="tfa_489"><span class="input-checkbox-faux"></span>Materials Mgmt/Purchasing</label></span><span class="oneChoice"><input type="checkbox" value="tfa_490" class="" id="tfa_490"
            name="tfa_490" aria-labelledby="tfa_490-L" data-tfa-labelledby="tfa_484-L tfa_490-L" disabled=""><label class="label postField" id="tfa_490-L" for="tfa_490"><span class="input-checkbox-faux"></span>Adminstration</label></span><span
          class="oneChoice"><input type="checkbox" value="tfa_491" class="" id="tfa_491" name="tfa_491" aria-labelledby="tfa_491-L" data-tfa-labelledby="tfa_484-L tfa_491-L" disabled=""><label class="label postField" id="tfa_491-L"
            for="tfa_491"><span class="input-checkbox-faux"></span>Environmental Services/Housekeeping</label></span><span class="oneChoice"><input type="checkbox" value="tfa_492" class="" id="tfa_492" name="tfa_492" aria-labelledby="tfa_492-L"
            data-tfa-labelledby="tfa_484-L tfa_492-L" disabled=""><label class="label postField" id="tfa_492-L" for="tfa_492"><span class="input-checkbox-faux"></span>Clinical/Lab - Vascular</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_493" class="" id="tfa_493" name="tfa_493" aria-labelledby="tfa_493-L" data-tfa-labelledby="tfa_484-L tfa_493-L" disabled=""><label class="label postField" id="tfa_493-L" for="tfa_493"><span
              class="input-checkbox-faux"></span>Clinical/Lab - GI</label></span><span class="oneChoice"><input type="checkbox" value="tfa_494" class="" id="tfa_494" name="tfa_494" aria-labelledby="tfa_494-L" data-tfa-labelledby="tfa_484-L tfa_494-L"
            disabled=""><label class="label postField" id="tfa_494-L" for="tfa_494"><span class="input-checkbox-faux"></span>Clinical/Lab - Cath</label></span><span class="oneChoice"><input type="checkbox" value="tfa_495" class="" id="tfa_495"
            name="tfa_495" aria-labelledby="tfa_495-L" data-tfa-labelledby="tfa_484-L tfa_495-L" disabled=""><label class="label postField" id="tfa_495-L" for="tfa_495"><span class="input-checkbox-faux"></span>Other</label></span></span></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_514-D">
    <label id="tfa_514-L" class="label preField reqMark" for="tfa_514">DSO Title</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_514" name="tfa_514" data-condition="`#tfa_429`" title="DSO Title" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_600" id="tfa_600" class="">C-Suite</option>
        <option value="tfa_601" id="tfa_601" class="">Administrator/President/VP</option>
        <option value="tfa_602" id="tfa_602" class="">Manager/Director/Department Head</option>
        <option value="tfa_603" id="tfa_603" class="">Assistant Manager/Director</option>
        <option value="tfa_604" id="tfa_604" class="">Supervisor/Coordinator</option>
        <option value="tfa_605" id="tfa_605" class="">Purchasing/Procurement/Supply Chain</option>
        <option value="tfa_606" id="tfa_606" class="">Other Executive</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_550-D">
    <label id="tfa_550-L" class="label preField reqMark" for="tfa_550">Number of Locations Affiliated With This Practice</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_550" name="tfa_550" data-condition="`#tfa_381`" title="Number of Locations Affiliated With This Practice" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_551" id="tfa_551" class="">one location</option>
        <option value="tfa_552" id="tfa_552" class="">2 to 5</option>
        <option value="tfa_553" id="tfa_553" class="">6 to 10</option>
        <option value="tfa_554" id="tfa_554" class="">11 to 20</option>
        <option value="tfa_555" id="tfa_555" class="">21 to 50</option>
        <option value="tfa_556" id="tfa_556" class="">more than 50</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_569-D" role="group" aria-labelledby="tfa_569-L" data-tfa-labelledby="-L tfa_569-L" aria-required="true">
    <label id="tfa_569-L" class="label preField reqMark" aria-label="Dental Type of Procedures &nbsp; required">Dental Type of Procedures</label><br>
    <div class="inputWrapper"><span id="tfa_569" class="choices vertical required" aria-required="true" data-condition="`#tfa_381`"><span class="oneChoice"><input type="checkbox" value="tfa_570" class="" id="tfa_570" name="tfa_570"
            aria-labelledby="tfa_570-L" data-tfa-labelledby="tfa_569-L tfa_570-L" disabled=""><label class="label postField" id="tfa_570-L" for="tfa_570"><span class="input-checkbox-faux"></span>Cosmetic</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_571" class="" id="tfa_571" name="tfa_571" aria-labelledby="tfa_571-L" data-tfa-labelledby="tfa_569-L tfa_571-L" disabled=""><label class="label postField" id="tfa_571-L" for="tfa_571"><span
              class="input-checkbox-faux"></span>Endodontic</label></span><span class="oneChoice"><input type="checkbox" value="tfa_572" class="" id="tfa_572" name="tfa_572" aria-labelledby="tfa_572-L" data-tfa-labelledby="tfa_569-L tfa_572-L"
            disabled=""><label class="label postField" id="tfa_572-L" for="tfa_572"><span class="input-checkbox-faux"></span>General Dentistry</label></span><span class="oneChoice"><input type="checkbox" value="tfa_573" class="" id="tfa_573"
            name="tfa_573" aria-labelledby="tfa_573-L" data-tfa-labelledby="tfa_569-L tfa_573-L" disabled=""><label class="label postField" id="tfa_573-L" for="tfa_573"><span class="input-checkbox-faux"></span>Implants</label></span><span
          class="oneChoice"><input type="checkbox" value="tfa_574" class="" id="tfa_574" name="tfa_574" aria-labelledby="tfa_574-L" data-tfa-labelledby="tfa_569-L tfa_574-L" disabled=""><label class="label postField" id="tfa_574-L"
            for="tfa_574"><span class="input-checkbox-faux"></span>Orthodontic</label></span><span class="oneChoice"><input type="checkbox" value="tfa_575" class="" id="tfa_575" name="tfa_575" aria-labelledby="tfa_575-L"
            data-tfa-labelledby="tfa_569-L tfa_575-L" disabled=""><label class="label postField" id="tfa_575-L" for="tfa_575"><span class="input-checkbox-faux"></span>Pediatric</label></span><span class="oneChoice"><input type="checkbox"
            value="tfa_576" class="" id="tfa_576" name="tfa_576" aria-labelledby="tfa_576-L" data-tfa-labelledby="tfa_569-L tfa_576-L" disabled=""><label class="label postField" id="tfa_576-L" for="tfa_576"><span
              class="input-checkbox-faux"></span>Periodontal</label></span><span class="oneChoice"><input type="checkbox" value="tfa_577" class="" id="tfa_577" name="tfa_577" aria-labelledby="tfa_577-L" data-tfa-labelledby="tfa_569-L tfa_577-L"
            disabled=""><label class="label postField" id="tfa_577-L" for="tfa_577"><span class="input-checkbox-faux"></span>Sleep Medicine</label></span></span></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_596-D">
    <label id="tfa_596-L" class="label preField reqMark" for="tfa_596">Pharmacy Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_596" name="tfa_596" data-condition="`#tfa_378`" title="Pharmacy Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_597" id="tfa_597" data-conditionals="#tfa_842,#tfa_1130,#tfa_1128" class="">Pharmacist</option>
        <option value="tfa_598" id="tfa_598" class="">Pharmacy Technician</option>
        <option value="tfa_599" id="tfa_599" class="">Pharmacy Student</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_611-D">
    <label id="tfa_611-L" class="label preField reqMark" for="tfa_611">Psychology Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_611" name="tfa_611" data-condition="`#tfa_380`" title="Psychology Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_612" id="tfa_612" class="">Psychologist</option>
        <option value="tfa_613" id="tfa_613" class="">Psychiatrist</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_617-D">
    <label id="tfa_617-L" class="label preField reqMark" for="tfa_617">Optometry Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_617" name="tfa_617" data-condition="`#tfa_379`" title="Optometry Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_618" id="tfa_618" class="">Optometrist</option>
        <option value="tfa_619" id="tfa_619" class="">Optician</option>
        <option value="tfa_620" id="tfa_620" class="">Ophthalmic Technician</option>
        <option value="tfa_621" id="tfa_621" class="">Optometric Technician</option>
        <option value="tfa_622" id="tfa_622" class="">Optometric Student</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_629-D">
    <label id="tfa_629-L" class="label preField reqMark" for="tfa_629">Psychology Area of Practice</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_629" name="tfa_629" data-condition="`#tfa_380`" title="Psychology Area of Practice" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_630" id="tfa_630" class="">Addiction</option>
        <option value="tfa_631" id="tfa_631" class="">Behavioral and Cognitive Psychology</option>
        <option value="tfa_632" id="tfa_632" class="">Brain injury medicine</option>
        <option value="tfa_633" id="tfa_633" class="">Child and adolescent psychiatry</option>
        <option value="tfa_634" id="tfa_634" class="">Clinical Child Psychology</option>
        <option value="tfa_635" id="tfa_635" class="">Clinical Health Psychology</option>
        <option value="tfa_636" id="tfa_636" class="">Clinical Neuro Psychology</option>
        <option value="tfa_637" id="tfa_637" class="">Clinical Neurophysiology</option>
        <option value="tfa_638" id="tfa_638" class="">Clinical Psychology</option>
        <option value="tfa_639" id="tfa_639" class="">Counseling Psychology</option>
        <option value="tfa_640" id="tfa_640" class="">Developemental Psychology</option>
        <option value="tfa_641" id="tfa_641" class="">Educational Psychology</option>
        <option value="tfa_642" id="tfa_642" class="">Family Psychology</option>
        <option value="tfa_643" id="tfa_643" class="">Forensic Psychiatry</option>
        <option value="tfa_644" id="tfa_644" class="">Forensic Psychology</option>
        <option value="tfa_645" id="tfa_645" class="">Geriatric psychiatry</option>
        <option value="tfa_646" id="tfa_646" class="">Hospice and palliative medicine</option>
        <option value="tfa_647" id="tfa_647" class="">Industrial-Organizational Psychology</option>
        <option value="tfa_648" id="tfa_648" class="">Neuropsychology</option>
        <option value="tfa_649" id="tfa_649" class="">Other</option>
        <option value="tfa_650" id="tfa_650" class="">Pain management</option>
        <option value="tfa_651" id="tfa_651" class="">Professional Geropsychology</option>
        <option value="tfa_652" id="tfa_652" class="">Psychoanalytic Psychology</option>
        <option value="tfa_653" id="tfa_653" class="">Psychosomatic medicine</option>
        <option value="tfa_654" id="tfa_654" class="">School Psychology</option>
        <option value="tfa_655" id="tfa_655" class="">Sleep medicine</option>
        <option value="tfa_656" id="tfa_656" class="">Social Psychology</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_657-D">
    <label id="tfa_657-L" class="label preField reqMark" for="tfa_657">Specialty</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_657" name="tfa_657" data-condition="`#tfa_373` OR `#tfa_374` OR `#tfa_375` OR `#tfa_376` OR `#tfa_377` OR `#tfa_393`" title="Specialty" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_658" id="tfa_658" class="">Allergy &amp; Clinical Immunology</option>
        <option value="tfa_659" id="tfa_659" class="">Anesthesiology</option>
        <option value="tfa_660" id="tfa_660" class="">Cardiology, Echocardiography</option>
        <option value="tfa_661" id="tfa_661" class="">Cardiology, Electrophysiology</option>
        <option value="tfa_662" id="tfa_662" class="">Cardiology, General</option>
        <option value="tfa_663" id="tfa_663" class="">Cardiology, Interventional</option>
        <option value="tfa_664" id="tfa_664" class="">Cardiology, Nuclear</option>
        <option value="tfa_665" id="tfa_665" class="">Cardiovascular Diseases</option>
        <option value="tfa_666" id="tfa_666" class="">Critical Care/Intensive Care</option>
        <option value="tfa_667" id="tfa_667" class="">Dermatology, Cosmetic</option>
        <option value="tfa_668" id="tfa_668" class="">Dermatology, General</option>
        <option value="tfa_669" id="tfa_669" class="">Dermatology, Pediatric</option>
        <option value="tfa_670" id="tfa_670" class="">Dermatopathology</option>
        <option value="tfa_671" id="tfa_671" class="">Diabetes</option>
        <option value="tfa_672" id="tfa_672" class="">Emergency Medicine</option>
        <option value="tfa_673" id="tfa_673" class="">Endocrinology</option>
        <option value="tfa_674" id="tfa_674" class="">Endocrinology, Reproductive/Infertility</option>
        <option value="tfa_675" id="tfa_675" class="">Epidemiology</option>
        <option value="tfa_676" id="tfa_676" class="">Family Medicine</option>
        <option value="tfa_677" id="tfa_677" class="">Gastroenterology</option>
        <option value="tfa_678" id="tfa_678" class="">General Practice</option>
        <option value="tfa_679" id="tfa_679" class="">Genomic Medicine</option>
        <option value="tfa_680" id="tfa_680" class="">Geriatrics</option>
        <option value="tfa_681" id="tfa_681" class="">Hematology</option>
        <option value="tfa_682" id="tfa_682" class="">Hepatology</option>
        <option value="tfa_683" id="tfa_683" class="">HIV/AIDS</option>
        <option value="tfa_684" id="tfa_684" class="">Hospice/Palliative Care</option>
        <option value="tfa_685" id="tfa_685" class="">Hospital Medicine</option>
        <option value="tfa_686" id="tfa_686" class="">Infectious Diseases</option>
        <option value="tfa_687" id="tfa_687" class="">Internal Medicine</option>
        <option value="tfa_688" id="tfa_688" class="">Internal Medicine, Sports Medicine</option>
        <option value="tfa_689" id="tfa_689" class="">Medical Genetics</option>
        <option value="tfa_690" id="tfa_690" class="">Neonatal/Perinatal Medicine</option>
        <option value="tfa_691" id="tfa_691" class="">Nephrology</option>
        <option value="tfa_692" id="tfa_692" class="">Neurology</option>
        <option value="tfa_693" id="tfa_693" class="">Neurosurgery</option>
        <option value="tfa_694" id="tfa_694" class="">Nuclear Medicine</option>
        <option value="tfa_695" id="tfa_695" class="">Nutrition</option>
        <option value="tfa_696" id="tfa_696" class="">Ob/Gyn &amp; Women's Health</option>
        <option value="tfa_697" id="tfa_697" class="">Oncology, Hematology </option>
        <option value="tfa_698" id="tfa_698" class="">Oncology, Medical</option>
        <option value="tfa_699" id="tfa_699" class="">Oncology, Other</option>
        <option value="tfa_700" id="tfa_700" class="">Oncology, Pediatric</option>
        <option value="tfa_701" id="tfa_701" class="">Oncology, Radiation</option>
        <option value="tfa_702" id="tfa_702" data-conditionals="#tfa_934" class="">Ophthalmology</option>
        <option value="tfa_703" id="tfa_703" class="">Orthopaedic Surgery</option>
        <option value="tfa_704" id="tfa_704" class="">Otolaryngology</option>
        <option value="tfa_705" id="tfa_705" class="">Pain Management</option>
        <option value="tfa_706" id="tfa_706" class="">Pathology</option>
        <option value="tfa_707" id="tfa_707" class="">Pediatrics, Allergy</option>
        <option value="tfa_708" id="tfa_708" class="">Pediatrics, Cardiology</option>
        <option value="tfa_709" id="tfa_709" class="">Pediatrics, General</option>
        <option value="tfa_710" id="tfa_710" class="">Pharmacology</option>
        <option value="tfa_711" id="tfa_711" class="">Physical Medicine &amp; Rehabilitation</option>
        <option value="tfa_712" id="tfa_712" class="">Plastic Surgery &amp; Aesthetic Medicine</option>
        <option value="tfa_713" id="tfa_713" class="">Preventive Medicine</option>
        <option value="tfa_714" id="tfa_714" class="">Psychiatry/Mental Health</option>
        <option value="tfa_715" id="tfa_715" class="">Public/Community Health</option>
        <option value="tfa_716" id="tfa_716" class="">Pulmonary Medicine</option>
        <option value="tfa_717" id="tfa_717" class="">Radiology</option>
        <option value="tfa_718" id="tfa_718" class="">Radiology, Interventional</option>
        <option value="tfa_719" id="tfa_719" class="">Rheumatology</option>
        <option value="tfa_720" id="tfa_720" class="">Surgery, Cardiothoracic</option>
        <option value="tfa_721" id="tfa_721" class="">Surgery, General</option>
        <option value="tfa_722" id="tfa_722" class="">Surgery, Head and Neck</option>
        <option value="tfa_723" id="tfa_723" class="">Surgery, Other</option>
        <option value="tfa_724" id="tfa_724" class="">Surgery, Surgical Oncology</option>
        <option value="tfa_725" id="tfa_725" class="">Surgery, Thoracic</option>
        <option value="tfa_726" id="tfa_726" class="">Surgery, Trauma</option>
        <option value="tfa_727" id="tfa_727" class="">Surgery, Vascular</option>
        <option value="tfa_728" id="tfa_728" class="">Transplantation</option>
        <option value="tfa_729" id="tfa_729" class="">Urology</option>
        <option value="tfa_730" id="tfa_730" class="">Vascular Medicine</option>
        <option value="tfa_731" id="tfa_731" class="">OTHER Clinical</option>
        <option value="tfa_732" id="tfa_732" class="">Non-Clinical</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_736-D">
    <label id="tfa_736-L" class="label preField reqMark" for="tfa_736">Health/Business Administration Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_736" name="tfa_736" data-condition="`#tfa_383`" title="Health/Business Administration Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_737" id="tfa_737" class="">Benefits Manager</option>
        <option value="tfa_738" id="tfa_738" class="">Case Manager</option>
        <option value="tfa_739" id="tfa_739" class="">CEO/President/Executive Director</option>
        <option value="tfa_740" id="tfa_740" class="">CFO/Finance</option>
        <option value="tfa_741" id="tfa_741" class="">Chief Marketing Officer/Chief Patient Experience Officer</option>
        <option value="tfa_742" id="tfa_742" class="">Chief Medical Officer/Chief of Staff</option>
        <option value="tfa_743" id="tfa_743" class="">CIO/CTO/Health IT Administrator</option>
        <option value="tfa_744" id="tfa_744" class="">COO/Operations Director</option>
        <option value="tfa_745" id="tfa_745" class="">Clinical Case Manager</option>
        <option value="tfa_746" id="tfa_746" class="">Clinical Program Director</option>
        <option value="tfa_747" id="tfa_747" class="">Clinical Researcher</option>
        <option value="tfa_748" id="tfa_748" class="">Director of Medical Affairs</option>
        <option value="tfa_749" id="tfa_749" class="">Health Business/Other</option>
        <option value="tfa_750" id="tfa_750" class="">Hospital Administrator</option>
        <option value="tfa_751" id="tfa_751" class="">Managed Care Director</option>
        <option value="tfa_752" id="tfa_752" class="">Marketer</option>
        <option value="tfa_753" id="tfa_753" class="">Medical Director</option>
        <option value="tfa_754" id="tfa_754" class="">Medical Educator/Librarian</option>
        <option value="tfa_755" id="tfa_755" data-conditionals="#tfa_1094" class="">Medical Office Manager</option>
        <option value="tfa_756" id="tfa_756" class="">Medicare/Medicaid Director</option>
        <option value="tfa_757" id="tfa_757" class="">MIS Director</option>
        <option value="tfa_758" id="tfa_758" class="">Other Healthcare Administrator</option>
        <option value="tfa_759" id="tfa_759" class="">Other Healthcare Executive</option>
        <option value="tfa_760" id="tfa_760" class="">Outcomes Researcher</option>
        <option value="tfa_761" id="tfa_761" class="">Pharmacy Administrator/Chief of Pharmacy Services</option>
        <option value="tfa_762" id="tfa_762" class="">Pharmacy/Formulary Director</option>
        <option value="tfa_763" id="tfa_763" data-conditionals="#tfa_1094" class="">Practice Manager/Administrator</option>
        <option value="tfa_764" id="tfa_764" class="">Quality Assurance Director</option>
        <option value="tfa_765" id="tfa_765" class="">Senior Executive</option>
        <option value="tfa_766" id="tfa_766" class="">Senior Manager</option>
        <option value="tfa_767" id="tfa_767" class="">Utilization Review Director</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_800-D">
    <label id="tfa_800-L" class="label preField reqMark" for="tfa_800">Other Healthcare Provider Role</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_800" name="tfa_800" data-condition="`#tfa_384`" title="Other Healthcare Provider Role" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_801" id="tfa_801" class="">Addiction Medicine</option>
        <option value="tfa_802" id="tfa_802" class="">Athletic/School Coach</option>
        <option value="tfa_803" id="tfa_803" class="">Childcare/Daycare Professional</option>
        <option value="tfa_804" id="tfa_804" class="">Chiropractor</option>
        <option value="tfa_805" id="tfa_805" class="">Counselor</option>
        <option value="tfa_806" id="tfa_806" class="">Esthetician</option>
        <option value="tfa_807" id="tfa_807" class="">Laboratory Technician</option>
        <option value="tfa_808" id="tfa_808" class="">Laboratory/Medical Technologist</option>
        <option value="tfa_809" id="tfa_809" class="">MRI Technologist</option>
        <option value="tfa_810" id="tfa_810" class="">Nuclear Medicine Technologist</option>
        <option value="tfa_811" id="tfa_811" class="">Nutritionist/Dietitian</option>
        <option value="tfa_812" id="tfa_812" class="">Other Medical/Clinical</option>
        <option value="tfa_813" id="tfa_813" class="">Other Technologist/Technician</option>
        <option value="tfa_814" id="tfa_814" class="">Paramedic/EMT</option>
        <option value="tfa_815" id="tfa_815" class="">Physical Therapist</option>
        <option value="tfa_816" id="tfa_816" class="">Podiatrist</option>
        <option value="tfa_817" id="tfa_817" class="">Radiation Therapist</option>
        <option value="tfa_818" id="tfa_818" class="">Radiology Technologist</option>
        <option value="tfa_819" id="tfa_819" class="">Rehab Specialist</option>
        <option value="tfa_820" id="tfa_820" class="">Social Worker</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_842-D">
    <label id="tfa_842-L" class="label preField reqMark" for="tfa_842">Pharmacy Area of Practice</label><br>
    <div class="inputWrapper"><select aria-required="true" id="tfa_842" name="tfa_842" data-condition="`#tfa_597`" title="Pharmacy Area of Practice" class="required" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_843" id="tfa_843" class="">Academia</option>
        <option value="tfa_844" id="tfa_844" class="">Addiction</option>
        <option value="tfa_845" id="tfa_845" class="">Ambulatory Care</option>
        <option value="tfa_846" id="tfa_846" class="">Anticoagulation</option>
        <option value="tfa_847" id="tfa_847" class="">Cardiology</option>
        <option value="tfa_848" id="tfa_848" class="">Community/Retail</option>
        <option value="tfa_849" id="tfa_849" class="">Compounding</option>
        <option value="tfa_850" id="tfa_850" class="">Critical Care</option>
        <option value="tfa_851" id="tfa_851" class="">Emergency Medicine</option>
        <option value="tfa_852" id="tfa_852" class="">Executive</option>
        <option value="tfa_853" id="tfa_853" class="">Geriatrics</option>
        <option value="tfa_854" id="tfa_854" class="">HIV/AIDS</option>
        <option value="tfa_855" id="tfa_855" class="">Hospital</option>
        <option value="tfa_856" id="tfa_856" class="">Industry</option>
        <option value="tfa_857" id="tfa_857" class="">Mail Order</option>
        <option value="tfa_858" id="tfa_858" class="">Managed Care</option>
        <option value="tfa_859" id="tfa_859" class="">Military</option>
        <option value="tfa_860" id="tfa_860" class="">None</option>
        <option value="tfa_861" id="tfa_861" class="">Nuclear Medicine</option>
        <option value="tfa_862" id="tfa_862" class="">Nutrition Support</option>
        <option value="tfa_863" id="tfa_863" class="">Oncology</option>
        <option value="tfa_864" id="tfa_864" class="">Pain Management</option>
        <option value="tfa_865" id="tfa_865" class="">Pharmacology</option>
        <option value="tfa_866" id="tfa_866" class="">Pharmacotherapy</option>
        <option value="tfa_867" id="tfa_867" class="">Psychiatry</option>
        <option value="tfa_868" id="tfa_868" class="">Specialty/Compounding</option>
        <option value="tfa_869" id="tfa_869" class="">Specialty/Retail</option>
        <option value="tfa_870" id="tfa_870" class="">Veterinary Medicine</option>
        <option value="tfa_871" id="tfa_871" class="">Other</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_902-D" role="group" aria-labelledby="tfa_902-L" data-tfa-labelledby="-L tfa_902-L" aria-required="true">
    <label id="tfa_902-L" class="label preField reqMark" aria-label="Optometry Area of Practice &nbsp; required">Optometry Area of Practice</label><br>
    <div class="inputWrapper"><span id="tfa_902" class="choices vertical required" aria-required="true" data-condition="`#tfa_379`"><span class="oneChoice"><input type="checkbox" value="tfa_903" class="" id="tfa_903" name="tfa_903"
            aria-labelledby="tfa_903-L" data-tfa-labelledby="tfa_902-L tfa_903-L" disabled=""><label class="label postField" id="tfa_903-L" for="tfa_903"><span class="input-checkbox-faux"></span>Allergy</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_904" class="" id="tfa_904" name="tfa_904" aria-labelledby="tfa_904-L" data-tfa-labelledby="tfa_902-L tfa_904-L" disabled=""><label class="label postField" id="tfa_904-L" for="tfa_904"><span
              class="input-checkbox-faux"></span>Cataract/Refractive Surgery Management</label></span><span class="oneChoice"><input type="checkbox" value="tfa_905" class="" id="tfa_905" name="tfa_905" aria-labelledby="tfa_905-L"
            data-tfa-labelledby="tfa_902-L tfa_905-L" disabled=""><label class="label postField" id="tfa_905-L" for="tfa_905"><span class="input-checkbox-faux"></span>Complementary Medicine/Nutrition</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_906" class="" id="tfa_906" name="tfa_906" aria-labelledby="tfa_906-L" data-tfa-labelledby="tfa_902-L tfa_906-L" disabled=""><label class="label postField" id="tfa_906-L" for="tfa_906"><span
              class="input-checkbox-faux"></span>Contact Lenses</label></span><span class="oneChoice"><input type="checkbox" value="tfa_907" class="" id="tfa_907" name="tfa_907" aria-labelledby="tfa_907-L" data-tfa-labelledby="tfa_902-L tfa_907-L"
            disabled=""><label class="label postField" id="tfa_907-L" for="tfa_907"><span class="input-checkbox-faux"></span>Cornea</label></span><span class="oneChoice"><input type="checkbox" value="tfa_908" class="" id="tfa_908" name="tfa_908"
            aria-labelledby="tfa_908-L" data-tfa-labelledby="tfa_902-L tfa_908-L" disabled=""><label class="label postField" id="tfa_908-L" for="tfa_908"><span class="input-checkbox-faux"></span>Dispensing</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_909" class="" id="tfa_909" name="tfa_909" aria-labelledby="tfa_909-L" data-tfa-labelledby="tfa_902-L tfa_909-L" disabled=""><label class="label postField" id="tfa_909-L" for="tfa_909"><span
              class="input-checkbox-faux"></span>External Disease</label></span><span class="oneChoice"><input type="checkbox" value="tfa_910" class="" id="tfa_910" name="tfa_910" aria-labelledby="tfa_910-L" data-tfa-labelledby="tfa_902-L tfa_910-L"
            disabled=""><label class="label postField" id="tfa_910-L" for="tfa_910"><span class="input-checkbox-faux"></span>Glaucoma</label></span><span class="oneChoice"><input type="checkbox" value="tfa_911" class="" id="tfa_911" name="tfa_911"
            aria-labelledby="tfa_911-L" data-tfa-labelledby="tfa_902-L tfa_911-L" disabled=""><label class="label postField" id="tfa_911-L" for="tfa_911"><span class="input-checkbox-faux"></span>Low Vision</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_912" class="" id="tfa_912" name="tfa_912" aria-labelledby="tfa_912-L" data-tfa-labelledby="tfa_902-L tfa_912-L" disabled=""><label class="label postField" id="tfa_912-L" for="tfa_912"><span
              class="input-checkbox-faux"></span>Neuro-Optometry/Binocular Vision</label></span><span class="oneChoice"><input type="checkbox" value="tfa_913" class="" id="tfa_913" name="tfa_913" aria-labelledby="tfa_913-L"
            data-tfa-labelledby="tfa_902-L tfa_913-L" disabled=""><label class="label postField" id="tfa_913-L" for="tfa_913"><span class="input-checkbox-faux"></span>Ocular Surface Disease/Dry Eye</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_914" class="" id="tfa_914" name="tfa_914" aria-labelledby="tfa_914-L" data-tfa-labelledby="tfa_902-L tfa_914-L" disabled=""><label class="label postField" id="tfa_914-L" for="tfa_914"><span
              class="input-checkbox-faux"></span>Ocular Pathology/Oncology</label></span><span class="oneChoice"><input type="checkbox" value="tfa_915" class="" id="tfa_915" name="tfa_915" aria-labelledby="tfa_915-L"
            data-tfa-labelledby="tfa_902-L tfa_915-L" disabled=""><label class="label postField" id="tfa_915-L" for="tfa_915"><span class="input-checkbox-faux"></span>Pediatrics</label></span><span class="oneChoice"><input type="checkbox"
            value="tfa_916" class="" id="tfa_916" name="tfa_916" aria-labelledby="tfa_916-L" data-tfa-labelledby="tfa_902-L tfa_916-L" disabled=""><label class="label postField" id="tfa_916-L" for="tfa_916"><span
              class="input-checkbox-faux"></span>Retina/Vitreous</label></span><span class="oneChoice"><input type="checkbox" value="tfa_917" class="" id="tfa_917" name="tfa_917" aria-labelledby="tfa_917-L" data-tfa-labelledby="tfa_902-L tfa_917-L"
            disabled=""><label class="label postField" id="tfa_917-L" for="tfa_917"><span class="input-checkbox-faux"></span>Vision Therapy and Rehabilitation</label></span></span></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_934-D" role="group" aria-labelledby="tfa_934-L" data-tfa-labelledby="-L tfa_934-L" aria-required="true">
    <label id="tfa_934-L" class="label preField reqMark" aria-label="Ophthalmology Area of Practice &nbsp; required">Ophthalmology Area of Practice</label><br>
    <div class="inputWrapper"><span id="tfa_934" class="choices vertical required" aria-required="true" data-condition="`#tfa_702`"><span class="oneChoice"><input type="checkbox" value="tfa_935" class="" id="tfa_935" name="tfa_935"
            aria-labelledby="tfa_935-L" data-tfa-labelledby="tfa_934-L tfa_935-L" disabled=""><label class="label postField" id="tfa_935-L" for="tfa_935"><span class="input-checkbox-faux"></span>Anterior Segment</label></span><span
          class="oneChoice"><input type="checkbox" value="tfa_936" class="" id="tfa_936" name="tfa_936" aria-labelledby="tfa_936-L" data-tfa-labelledby="tfa_934-L tfa_936-L" disabled=""><label class="label postField" id="tfa_936-L"
            for="tfa_936"><span class="input-checkbox-faux"></span>Brain Injury Vision Rehabilitation</label></span><span class="oneChoice"><input type="checkbox" value="tfa_937" class="" id="tfa_937" name="tfa_937" aria-labelledby="tfa_937-L"
            data-tfa-labelledby="tfa_934-L tfa_937-L" disabled=""><label class="label postField" id="tfa_937-L" for="tfa_937"><span class="input-checkbox-faux"></span>Cataract/Refractive Surgery </label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_938" class="" id="tfa_938" name="tfa_938" aria-labelledby="tfa_938-L" data-tfa-labelledby="tfa_934-L tfa_938-L" disabled=""><label class="label postField" id="tfa_938-L" for="tfa_938"><span
              class="input-checkbox-faux"></span>Cornea/External Disease</label></span><span class="oneChoice"><input type="checkbox" value="tfa_939" class="" id="tfa_939" name="tfa_939" aria-labelledby="tfa_939-L"
            data-tfa-labelledby="tfa_934-L tfa_939-L" disabled=""><label class="label postField" id="tfa_939-L" for="tfa_939"><span class="input-checkbox-faux"></span>Glaucoma</label></span><span class="oneChoice"><input type="checkbox"
            value="tfa_940" class="" id="tfa_940" name="tfa_940" aria-labelledby="tfa_940-L" data-tfa-labelledby="tfa_934-L tfa_940-L" disabled=""><label class="label postField" id="tfa_940-L" for="tfa_940"><span
              class="input-checkbox-faux"></span>Low Vision Rehabilitation</label></span><span class="oneChoice"><input type="checkbox" value="tfa_941" class="" id="tfa_941" name="tfa_941" aria-labelledby="tfa_941-L"
            data-tfa-labelledby="tfa_934-L tfa_941-L" disabled=""><label class="label postField" id="tfa_941-L" for="tfa_941"><span class="input-checkbox-faux"></span>Neuro-Ophthalmology</label></span><span class="oneChoice"><input type="checkbox"
            value="tfa_942" class="" id="tfa_942" name="tfa_942" aria-labelledby="tfa_942-L" data-tfa-labelledby="tfa_934-L tfa_942-L" disabled=""><label class="label postField" id="tfa_942-L" for="tfa_942"><span
              class="input-checkbox-faux"></span>Ocular Disease</label></span><span class="oneChoice"><input type="checkbox" value="tfa_943" class="" id="tfa_943" name="tfa_943" aria-labelledby="tfa_943-L" data-tfa-labelledby="tfa_934-L tfa_943-L"
            disabled=""><label class="label postField" id="tfa_943-L" for="tfa_943"><span class="input-checkbox-faux"></span>Ocular Pathology/Oncology</label></span><span class="oneChoice"><input type="checkbox" value="tfa_944" class="" id="tfa_944"
            name="tfa_944" aria-labelledby="tfa_944-L" data-tfa-labelledby="tfa_934-L tfa_944-L" disabled=""><label class="label postField" id="tfa_944-L" for="tfa_944"><span class="input-checkbox-faux"></span>Oculoplastics/Orbit</label></span><span
          class="oneChoice"><input type="checkbox" value="tfa_945" class="" id="tfa_945" name="tfa_945" aria-labelledby="tfa_945-L" data-tfa-labelledby="tfa_934-L tfa_945-L" disabled=""><label class="label postField" id="tfa_945-L"
            for="tfa_945"><span class="input-checkbox-faux"></span>Pediatric Ophthalmology/Strabismus</label></span><span class="oneChoice"><input type="checkbox" value="tfa_946" class="" id="tfa_946" name="tfa_946" aria-labelledby="tfa_946-L"
            data-tfa-labelledby="tfa_934-L tfa_946-L" disabled=""><label class="label postField" id="tfa_946-L" for="tfa_946"><span class="input-checkbox-faux"></span>Pharmacology</label></span><span class="oneChoice"><input type="checkbox"
            value="tfa_947" class="" id="tfa_947" name="tfa_947" aria-labelledby="tfa_947-L" data-tfa-labelledby="tfa_934-L tfa_947-L" disabled=""><label class="label postField" id="tfa_947-L" for="tfa_947"><span
              class="input-checkbox-faux"></span>Refractive and Ocular Surgery</label></span><span class="oneChoice"><input type="checkbox" value="tfa_948" class="" id="tfa_948" name="tfa_948" aria-labelledby="tfa_948-L"
            data-tfa-labelledby="tfa_934-L tfa_948-L" disabled=""><label class="label postField" id="tfa_948-L" for="tfa_948"><span class="input-checkbox-faux"></span>Retina/Vitreous Retinal Disorders</label></span><span class="oneChoice"><input
            type="checkbox" value="tfa_949" class="" id="tfa_949" name="tfa_949" aria-labelledby="tfa_949-L" data-tfa-labelledby="tfa_934-L tfa_949-L" disabled=""><label class="label postField" id="tfa_949-L" for="tfa_949"><span
              class="input-checkbox-faux"></span>Uveitis</label></span><span class="oneChoice"><input type="checkbox" value="tfa_950" class="" id="tfa_950" name="tfa_950" aria-labelledby="tfa_950-L" data-tfa-labelledby="tfa_934-L tfa_950-L"
            disabled=""><label class="label postField" id="tfa_950-L" for="tfa_950"><span class="input-checkbox-faux"></span>Vision Therapy and Rehabilitation</label></span><span class="oneChoice"><input type="checkbox" value="tfa_951" class=""
            id="tfa_951" name="tfa_951" aria-labelledby="tfa_951-L" data-tfa-labelledby="tfa_934-L tfa_951-L" disabled=""><label class="label postField" id="tfa_951-L" for="tfa_951"><span class="input-checkbox-faux"></span>Other</label></span></span>
    </div>
  </div>
  <div class="oneField field-container-D    " id="tfa_982-D">
    <label id="tfa_982-L" class="label preField " for="tfa_982">Workplace</label><br>
    <div class="inputWrapper"><select id="tfa_982" name="tfa_982" data-condition="NOT (`#tfa_394`) AND NOT (`#tfa_392`)" title="Workplace" class="">
        <option value="">Please select...</option>
        <option value="tfa_983" id="tfa_983" class="">Academic</option>
        <option value="tfa_984" id="tfa_984" class="">Advertising Agency</option>
        <option value="tfa_985" id="tfa_985" class="">Biotechnology Company</option>
        <option value="tfa_986" id="tfa_986" class="">Cancer Center</option>
        <option value="tfa_987" id="tfa_987" class="">Cancer Registry</option>
        <option value="tfa_988" id="tfa_988" class="">Clinic</option>
        <option value="tfa_989" id="tfa_989" class="">Government (VA, DOD, etc.)</option>
        <option value="tfa_990" id="tfa_990" class="">Home Health (VNA, Hospice)</option>
        <option value="tfa_991" id="tfa_991" data-conditionals="#tfa_1078" class="">Hospital</option>
        <option value="tfa_992" id="tfa_992" data-conditionals="#tfa_1078" class="">Hospital, Emergency Room</option>
        <option value="tfa_993" id="tfa_993" class="">IHO/IHN</option>
        <option value="tfa_994" id="tfa_994" class="">Insurance Company</option>
        <option value="tfa_995" id="tfa_995" class="">Laboratory, Clinical</option>
        <option value="tfa_996" id="tfa_996" class="">Laboratory, Dental</option>
        <option value="tfa_997" id="tfa_997" class="">Laboratory, Research</option>
        <option value="tfa_998" id="tfa_998" class="">Long Term Care Facility</option>
        <option value="tfa_999" id="tfa_999" class="">Managed Care Organization</option>
        <option value="tfa_1000" id="tfa_1000" class="">Market Segment</option>
        <option value="tfa_1001" id="tfa_1001" data-conditionals="#tfa_1094,#tfa_1062,#tfa_1046" class="">Medical Practice, Group</option>
        <option value="tfa_1002" id="tfa_1002" data-conditionals="#tfa_1094,#tfa_1062,#tfa_1046" class="">Medical Practice, Private</option>
        <option value="tfa_1003" id="tfa_1003" class="">Medical School</option>
        <option value="tfa_1004" id="tfa_1004" class="">Medicare/Medicaid</option>
        <option value="tfa_1005" id="tfa_1005" class="">Optometry, Corporate/Franchise </option>
        <option value="tfa_1006" id="tfa_1006" class="">Optometry, Independent/Private Practice</option>
        <option value="tfa_1007" id="tfa_1007" class="">Outpatient/Surgery Center</option>
        <option value="tfa_1008" id="tfa_1008" class="">PBM/PDP/EBM</option>
        <option value="tfa_1009" id="tfa_1009" class="">Pharmaceutical Company</option>
        <option value="tfa_1010" id="tfa_1010" class="">Pharmacy, Chain (4 or more stores)</option>
        <option value="tfa_1011" id="tfa_1011" class="">Pharmacy, Hospital</option>
        <option value="tfa_1012" id="tfa_1012" class="">Pharmacy, Independent (1-3 stores)</option>
        <option value="tfa_1013" id="tfa_1013" class="">Other</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_1046-D">
    <label id="tfa_1046-L" class="label preField " for="tfa_1046">Group Size</label><br>
    <div class="inputWrapper"><select id="tfa_1046" name="tfa_1046" data-condition="`#tfa_1001` OR `#tfa_1002`" title="Group Size" class="" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_1047" id="tfa_1047" class="">1 to 5</option>
        <option value="tfa_1048" id="tfa_1048" class="">6 to 10 </option>
        <option value="tfa_1049" id="tfa_1049" class="">11 to 30</option>
        <option value="tfa_1050" id="tfa_1050" class="">31 to 50</option>
        <option value="tfa_1051" id="tfa_1051" class="">51 to 100</option>
        <option value="tfa_1052" id="tfa_1052" class="">101 to 300 </option>
        <option value="tfa_1053" id="tfa_1053" class="">301+</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_1062-D">
    <label id="tfa_1062-L" class="label preField " for="tfa_1062">Group Ownership</label><br>
    <div class="inputWrapper"><select id="tfa_1062" name="tfa_1062" data-condition="`#tfa_1001` OR `#tfa_1002`" title="Group Ownership" class="" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_1210" id="tfa_1210" class="">Independent, no hospital affiliation</option>
        <option value="tfa_1211" id="tfa_1211" class="">Independent, with hospital affiliation</option>
        <option value="tfa_1212" id="tfa_1212" class="">Employed (by hospital/health system/group practice)</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_1078-D">
    <label id="tfa_1078-L" class="label preField " for="tfa_1078">Hospital Type</label><br>
    <div class="inputWrapper"><select id="tfa_1078" name="tfa_1078" data-condition="`#tfa_991` OR `#tfa_992`" title="Hospital Type" class="" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_1206" id="tfa_1206" class="">Academic</option>
        <option value="tfa_1207" id="tfa_1207" class="">Health System</option>
        <option value="tfa_1208" id="tfa_1208" class="">Community</option>
        <option value="tfa_1209" id="tfa_1209" class="">Rural</option>
      </select></div>
  </div>
  <div class="oneField field-container-D     offstate" id="tfa_1094-D">
    <label id="tfa_1094-L" class="label preField " for="tfa_1094">Workplace Specialty</label><br>
    <div class="inputWrapper"><select id="tfa_1094" name="tfa_1094" data-condition="`#tfa_1001` OR `#tfa_1002` OR `#tfa_755` OR `#tfa_763`" title="Workplace Specialty" class="" disabled="">
        <option value="">Please select...</option>
        <option value="tfa_1131" id="tfa_1131" class="">Allergy &amp; Clinical Immunology</option>
        <option value="tfa_1132" id="tfa_1132" class="">Anesthesiology</option>
        <option value="tfa_1133" id="tfa_1133" class="">Cardiology, Echocardiography</option>
        <option value="tfa_1134" id="tfa_1134" class="">Cardiology, Electrophysiology</option>
        <option value="tfa_1135" id="tfa_1135" class="">Cardiology, General</option>
        <option value="tfa_1136" id="tfa_1136" class="">Cardiology, Interventional</option>
        <option value="tfa_1137" id="tfa_1137" class="">Cardiology, Nuclear</option>
        <option value="tfa_1138" id="tfa_1138" class="">Cardiovascular Diseases</option>
        <option value="tfa_1139" id="tfa_1139" class="">Critical Care/Intensive Care</option>
        <option value="tfa_1140" id="tfa_1140" class="">Dermatology, Cosmetic</option>
        <option value="tfa_1141" id="tfa_1141" class="">Dermatology, General</option>
        <option value="tfa_1142" id="tfa_1142" class="">Dermatology, Pediatric</option>
        <option value="tfa_1143" id="tfa_1143" class="">Dermatopathology</option>
        <option value="tfa_1144" id="tfa_1144" class="">Diabetes</option>
        <option value="tfa_1145" id="tfa_1145" class="">Emergency Medicine</option>
        <option value="tfa_1146" id="tfa_1146" class="">Endocrinology</option>
        <option value="tfa_1147" id="tfa_1147" class="">Endocrinology, Reproductive/Infertility</option>
        <option value="tfa_1148" id="tfa_1148" class="">Epidemiology</option>
        <option value="tfa_1149" id="tfa_1149" class="">Family Medicine</option>
        <option value="tfa_1150" id="tfa_1150" class="">Gastroenterology</option>
        <option value="tfa_1151" id="tfa_1151" class="">General Practice</option>
        <option value="tfa_1152" id="tfa_1152" class="">Genomic Medicine</option>
        <option value="tfa_1153" id="tfa_1153" class="">Geriatrics</option>
        <option value="tfa_1154" id="tfa_1154" class="">Hematology</option>
        <option value="tfa_1155" id="tfa_1155" class="">Hepatology</option>
        <option value="tfa_1156" id="tfa_1156" class="">HIV/AIDS</option>
        <option value="tfa_1157" id="tfa_1157" class="">Hospice/Palliative Care</option>
        <option value="tfa_1158" id="tfa_1158" class="">Hospital Medicine</option>
        <option value="tfa_1159" id="tfa_1159" class="">Infectious Diseases</option>
        <option value="tfa_1160" id="tfa_1160" class="">Internal Medicine</option>
        <option value="tfa_1161" id="tfa_1161" class="">Internal Medicine, Sports Medicine</option>
        <option value="tfa_1162" id="tfa_1162" class="">Medical Genetics</option>
        <option value="tfa_1163" id="tfa_1163" class="">Neonatal/Perinatal Medicine</option>
        <option value="tfa_1164" id="tfa_1164" class="">Nephrology</option>
        <option value="tfa_1165" id="tfa_1165" class="">Neurology</option>
        <option value="tfa_1166" id="tfa_1166" class="">Neurosurgery</option>
        <option value="tfa_1167" id="tfa_1167" class="">Nuclear Medicine</option>
        <option value="tfa_1168" id="tfa_1168" class="">Nutrition</option>
        <option value="tfa_1169" id="tfa_1169" class="">Ob/Gyn &amp; Women's Health</option>
        <option value="tfa_1170" id="tfa_1170" class="">Oncology, Hematology </option>
        <option value="tfa_1171" id="tfa_1171" class="">Oncology, Medical</option>
        <option value="tfa_1172" id="tfa_1172" class="">Oncology, Other</option>
        <option value="tfa_1173" id="tfa_1173" class="">Oncology, Pediatric</option>
        <option value="tfa_1174" id="tfa_1174" class="">Oncology, Radiation</option>
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Text Content

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anonymousid


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Title


Company Name


Country

Please select... Afghanistan Albania Algeria American Samoa Andorra Angola
Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia
Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize
Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island
Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi
Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad
Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo
Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech
Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor
Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland
Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French
Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia
Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala
Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras
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Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos
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Phone

11 characters left.
Occupation

Please select... Physician Physician Assistant Nurse/Advanced Practice Nurse
Medical Student Resident/Fellow Pharmacy Professional
Optometrist/Optician/Ophthalmic Technician Psychiatry/Psychology Professional
Dental/Oral Health Provider/DSO Infection Control Health/Business Administration
Other Health Care Provider Patient Medical Science Liasion Media/Press
Patient Role

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Nurse/Advanced Practice Nurse Role

Please select... Clinical Nurse Specialist Licensed Practical Nurse (LPN/LVN)
Nurse Anethesist Nurse Midwife Nurse Practicioner (NP) Nursing Student
Registered Nurse (RN) Director of Nursing
Dental Role

Please select... Dental Anesthesiologist Dentist Dentist, Owner/President Dental
Assistant Dental Hygienist Dental Student Dental Technician Dental Support
Organization (DSO) Director/Instructor Endodontist Office Manager/Administrator
Oral Pathologist Orthodontist Other Owner or Manager of Dental Labs Pediatric
Dentist Periodontist Prosthodontist Sales Representative Surgeon, Cosmetic
Surgeon, Oral & Maxillofacial
Infection Control Role

Please select... Infection Preventionist (IP) Infection Control Practicioner
(ICP) C-Suite Chief Nursing Officer/Director of Nursing/Director of Infection
Prevention NP/RN/Nurse Administrator/President/VP Manager/Director/Department
Head Assistant Manager/Director Supervisor/Coordinator
Purchasing/Procurement/Supply Chain Technician Physician Patient Safety
Officer/Supervisor/Specialist Risk Manager Quality Improvement
Supervisor/Specialist Consultant Other (please specify)
Infection Control Role: Other (please specify)


Infection Control Area of Focus

Infection ControlOR/SurgerySterile Processing/Cs/SpdNursingMaterials
Mgmt/PurchasingAdminstrationEnvironmental Services/HousekeepingClinical/Lab -
VascularClinical/Lab - GIClinical/Lab - CathOther
DSO Title

Please select... C-Suite Administrator/President/VP Manager/Director/Department
Head Assistant Manager/Director Supervisor/Coordinator
Purchasing/Procurement/Supply Chain Other Executive
Number of Locations Affiliated With This Practice

Please select... one location 2 to 5 6 to 10 11 to 20 21 to 50 more than 50
Dental Type of Procedures

CosmeticEndodonticGeneral DentistryImplantsOrthodonticPediatricPeriodontalSleep
Medicine
Pharmacy Role

Please select... Pharmacist Pharmacy Technician Pharmacy Student
Psychology Role

Please select... Psychologist Psychiatrist
Optometry Role

Please select... Optometrist Optician Ophthalmic Technician Optometric
Technician Optometric Student
Psychology Area of Practice

Please select... Addiction Behavioral and Cognitive Psychology Brain injury
medicine Child and adolescent psychiatry Clinical Child Psychology Clinical
Health Psychology Clinical Neuro Psychology Clinical Neurophysiology Clinical
Psychology Counseling Psychology Developemental Psychology Educational
Psychology Family Psychology Forensic Psychiatry Forensic Psychology Geriatric
psychiatry Hospice and palliative medicine Industrial-Organizational Psychology
Neuropsychology Other Pain management Professional Geropsychology Psychoanalytic
Psychology Psychosomatic medicine School Psychology Sleep medicine Social
Psychology
Specialty

Please select... Allergy & Clinical Immunology Anesthesiology Cardiology,
Echocardiography Cardiology, Electrophysiology Cardiology, General Cardiology,
Interventional Cardiology, Nuclear Cardiovascular Diseases Critical
Care/Intensive Care Dermatology, Cosmetic Dermatology, General Dermatology,
Pediatric Dermatopathology Diabetes Emergency Medicine Endocrinology
Endocrinology, Reproductive/Infertility Epidemiology Family Medicine
Gastroenterology General Practice Genomic Medicine Geriatrics Hematology
Hepatology HIV/AIDS Hospice/Palliative Care Hospital Medicine Infectious
Diseases Internal Medicine Internal Medicine, Sports Medicine Medical Genetics
Neonatal/Perinatal Medicine Nephrology Neurology Neurosurgery Nuclear Medicine
Nutrition Ob/Gyn & Women's Health Oncology, Hematology Oncology, Medical
Oncology, Other Oncology, Pediatric Oncology, Radiation Ophthalmology
Orthopaedic Surgery Otolaryngology Pain Management Pathology Pediatrics, Allergy
Pediatrics, Cardiology Pediatrics, General Pharmacology Physical Medicine &
Rehabilitation Plastic Surgery & Aesthetic Medicine Preventive Medicine
Psychiatry/Mental Health Public/Community Health Pulmonary Medicine Radiology
Radiology, Interventional Rheumatology Surgery, Cardiothoracic Surgery, General
Surgery, Head and Neck Surgery, Other Surgery, Surgical Oncology Surgery,
Thoracic Surgery, Trauma Surgery, Vascular Transplantation Urology Vascular
Medicine OTHER Clinical Non-Clinical
Health/Business Administration Role

Please select... Benefits Manager Case Manager CEO/President/Executive Director
CFO/Finance Chief Marketing Officer/Chief Patient Experience Officer Chief
Medical Officer/Chief of Staff CIO/CTO/Health IT Administrator COO/Operations
Director Clinical Case Manager Clinical Program Director Clinical Researcher
Director of Medical Affairs Health Business/Other Hospital Administrator Managed
Care Director Marketer Medical Director Medical Educator/Librarian Medical
Office Manager Medicare/Medicaid Director MIS Director Other Healthcare
Administrator Other Healthcare Executive Outcomes Researcher Pharmacy
Administrator/Chief of Pharmacy Services Pharmacy/Formulary Director Practice
Manager/Administrator Quality Assurance Director Senior Executive Senior Manager
Utilization Review Director
Other Healthcare Provider Role

Please select... Addiction Medicine Athletic/School Coach Childcare/Daycare
Professional Chiropractor Counselor Esthetician Laboratory Technician
Laboratory/Medical Technologist MRI Technologist Nuclear Medicine Technologist
Nutritionist/Dietitian Other Medical/Clinical Other Technologist/Technician
Paramedic/EMT Physical Therapist Podiatrist Radiation Therapist Radiology
Technologist Rehab Specialist Social Worker
Pharmacy Area of Practice

Please select... Academia Addiction Ambulatory Care Anticoagulation Cardiology
Community/Retail Compounding Critical Care Emergency Medicine Executive
Geriatrics HIV/AIDS Hospital Industry Mail Order Managed Care Military None
Nuclear Medicine Nutrition Support Oncology Pain Management Pharmacology
Pharmacotherapy Psychiatry Specialty/Compounding Specialty/Retail Veterinary
Medicine Other
Optometry Area of Practice

AllergyCataract/Refractive Surgery ManagementComplementary
Medicine/NutritionContact LensesCorneaDispensingExternal DiseaseGlaucomaLow
VisionNeuro-Optometry/Binocular VisionOcular Surface Disease/Dry EyeOcular
Pathology/OncologyPediatricsRetina/VitreousVision Therapy and Rehabilitation
Ophthalmology Area of Practice

Anterior SegmentBrain Injury Vision RehabilitationCataract/Refractive Surgery
Cornea/External DiseaseGlaucomaLow Vision
RehabilitationNeuro-OphthalmologyOcular DiseaseOcular
Pathology/OncologyOculoplastics/OrbitPediatric
Ophthalmology/StrabismusPharmacologyRefractive and Ocular SurgeryRetina/Vitreous
Retinal DisordersUveitisVision Therapy and RehabilitationOther
Workplace

Please select... Academic Advertising Agency Biotechnology Company Cancer Center
Cancer Registry Clinic Government (VA, DOD, etc.) Home Health (VNA, Hospice)
Hospital Hospital, Emergency Room IHO/IHN Insurance Company Laboratory, Clinical
Laboratory, Dental Laboratory, Research Long Term Care Facility Managed Care
Organization Market Segment Medical Practice, Group Medical Practice, Private
Medical School Medicare/Medicaid Optometry, Corporate/Franchise Optometry,
Independent/Private Practice Outpatient/Surgery Center PBM/PDP/EBM
Pharmaceutical Company Pharmacy, Chain (4 or more stores) Pharmacy, Hospital
Pharmacy, Independent (1-3 stores) Other
Group Size

Please select... 1 to 5 6 to 10 11 to 30 31 to 50 51 to 100 101 to 300 301+
Group Ownership

Please select... Independent, no hospital affiliation Independent, with hospital
affiliation Employed (by hospital/health system/group practice)
Hospital Type

Please select... Academic Health System Community Rural
Workplace Specialty

Please select... Allergy & Clinical Immunology Anesthesiology Cardiology,
Echocardiography Cardiology, Electrophysiology Cardiology, General Cardiology,
Interventional Cardiology, Nuclear Cardiovascular Diseases Critical
Care/Intensive Care Dermatology, Cosmetic Dermatology, General Dermatology,
Pediatric Dermatopathology Diabetes Emergency Medicine Endocrinology
Endocrinology, Reproductive/Infertility Epidemiology Family Medicine
Gastroenterology General Practice Genomic Medicine Geriatrics Hematology
Hepatology HIV/AIDS Hospice/Palliative Care Hospital Medicine Infectious
Diseases Internal Medicine Internal Medicine, Sports Medicine Medical Genetics
Neonatal/Perinatal Medicine Nephrology Neurology Neurosurgery Nuclear Medicine
Nutrition Ob/Gyn & Women's Health Oncology, Hematology Oncology, Medical
Oncology, Other Oncology, Pediatric Oncology, Radiation Ophthalmology
Orthopaedic Surgery Otolaryngology Pain Management Pathology Pediatrics, Allergy
Pediatrics, Cardiology Pediatrics, General Pharmacology Physical Medicine &
Rehabilitation Plastic Surgery & Aesthetic Medicine Preventive Medicine
Psychiatry/Mental Health Public/Community Health Pulmonary Medicine Radiology
Radiology, Interventional Rheumatology Surgery, Cardiothoracic Surgery, General
Surgery, Head and Neck Surgery, Other Surgery, Surgical Oncology Surgery,
Thoracic Surgery, Trauma Surgery, Vascular Transplantation Urology Vascular
Medicine OTHER Clinical Non-Clinical
Graduation Year

4 characters left.
NPI Number

10 characters left.
Medical School


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