maximushelpdeskcdc.my.salesforce-sites.com
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Submitted URL: https://maximushelpdesk-cdc.secure.force.com/
Effective URL: https://maximushelpdeskcdc.my.salesforce-sites.com/VAMS/
Submission: On May 24 via api from US — Scanned from US
Effective URL: https://maximushelpdeskcdc.my.salesforce-sites.com/VAMS/
Submission: On May 24 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
Name: j_id0:j_id4 — POST /VAMS/NewServiceRequestVAMS
<form id="j_id0:j_id4" name="j_id0:j_id4" method="post" action="/VAMS/NewServiceRequestVAMS" enctype="multipart/form-data">
<input type="hidden" name="j_id0:j_id4" value="j_id0:j_id4">
<div class="slds-spinner_container slds-hide" id="mainSpinner">
<div class="slds-spinner slds-spinner_medium" id="mySpinner" role="status">
<span class="slds-assistive-text">Loading</span>
<div class="slds-spinner__dot-a"></div>
<div class="slds-spinner__dot-b"></div>
</div>
</div>
<div class="slds-box" style="background-color:lavenderblush;font-size:20px">
<center>
<p><b>VAMS (Vaccine Administration Management System) New Service Request</b></p>
</center>
</div><span id="j_id0:j_id4:j_id6"></span>
<div class="slds-box slds-text-heading_small" style="font-size:15px !important;">
<script>
if (!window.sfdcPage) {
window.sfdcPage = new ApexDetailPage();
}
UserContext.initialize({
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"dateFormat": "M/d/yyyy",
"language": "en_US",
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"dateTimeFormat": "M/d/yyyy, h:mm a",
"labelLastModified": "1684354322000",
"today": "5/24/2023, 8:47 AM",
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"name": "HideKnowledgeFirstTimeSetupMsg",
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"name": "HideNewCsnSplash",
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"name": "HideSetupProfileHeaderTour",
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"name": "ShowDevContextMenu",
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}, {
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"name": "HideWhatRecommenderForActivityQueues",
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}, {
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"name": "HideLiveAgentFirstTimeSetupMsg",
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}, {
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"name": "HideGroupAllowsGuestsMsgOnMemberWidget",
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}, {
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"name": "HideGroupAllowsGuestsMsg",
"value": false
}, {
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"name": "HideWhatAreGuestsMsg",
"value": false
}, {
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"name": "HideNowAllowGuestsMsg",
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"name": "HideSocialAccountsAndContactsGuidedTour",
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"name": "HideAnalyticsHomeGuidedTour",
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"name": "HideFileSyncBannerMsg",
"value": false
}, {
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"name": "HideTestConsoleGuidedTour",
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"name": "HideManyWhoInlineEditTip",
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"name": "HideSetupV2WelcomeMessage",
"value": false
}, {
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"name": "ForecastingShowQuantity",
"value": false
}, {
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"name": "HideDataImporterIntroMsg",
"value": false
}, {
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"name": "HideEnvironmentHubLightbox",
"value": false
}, {
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"name": "HideSetupV2GuidedTour",
"value": false
}, {
"index": 317,
"name": "HideFileSyncMobileDownloadDialog",
"value": false
}, {
"index": 322,
"name": "HideEnhancedProfileHelpBubble",
"value": false
}, {
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"name": "ForecastingHideZeroRows",
"value": false
}, {
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"name": "HideEmbeddedComponentsFeatureCallout",
"value": false
}, {
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"name": "HideDedupeMatchResultCallout",
"value": false
}, {
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"name": "HideS1BrowserUI",
"value": false
}, {
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"name": "HideS1Banner",
"value": false
}, {
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"name": "HideEmailVerificationAlert",
"value": false
}, {
"index": 354,
"name": "HideLearningPathModal",
"value": false
}, {
"index": 359,
"name": "HideAtMentionsHelpBubble",
"value": false
}, {
"index": 368,
"name": "LightningExperiencePreferred",
"value": true
}, {
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"name": "PreviewLightning",
"value": false
}],
"networkId": "",
"uiTheme": "Theme3",
"uiSkin": "Theme3",
"userName": "vams_form@maximushelpdesk-cdc.force.com",
"userId": "0053d000002wbQW",
"isCurrentlySysAdminSU": false,
"renderMode": "RETRO",
"startOfWeek": "1",
"vfDomainPattern": "maximushelpdeskcdc--(?:[^.]+).vf.force.com",
"auraDomain": "maximushelpdeskcdc.lightning.force.com",
"useNativeAlertConfirmPrompt": false,
"orgPreferences": [{
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"name": "TabOrganizer",
"value": true
}, {
"index": 113,
"name": "GroupTasks",
"value": true
}],
"siteUrlPrefix": "/VAMS",
"isDefaultNetwork": true,
"timeFormat": "h:mm a"
});
</script>
<div class="apexp">
<div id="j_id0:j_id4:myBlock" class="bPageBlock brandSecondaryBrd apexDefaultPageBlock secondaryPalette">
<script>
function twistSection(elem, sectionId) {
var parentDiv = elem;
var twisty = elem;
while (parentDiv.tagName != 'DIV') {
parentDiv = parentDiv.parentNode;
}
if (elem.tagName === 'DIV' && elem.attributes['data-twistyimgid'] !== undefined) {
twisty = document.getElementById(elem.attributes['data-twistyimgid'].value);
}
var div = parentDiv.nextSibling;
var elemWasOn = false;
if (div.style.display != 'none') {
div.style.display = 'none';
twisty.className = 'showListButton';
twisty.alt = 'Show Section - ' + twisty.name;
elem.title = twisty.alt;
elemWasOn = true;
} else {
div.style.display = 'block';
twisty.className = 'hideListButton';
twisty.alt = 'Hide Section - ' + twisty.name;
elem.title = twisty.alt;
}
return !elemWasOn;
}
var registeredSections = new Array();
function registerTwistableSection(headerId, mainTableId) {
var obj = new Object();
obj.headerId = headerId;
obj.mainTableId = mainTableId;
registeredSections[registeredSections.length] = obj;
}
function twistAllSections(on) {
for (var i = 0; i < registeredSections.length; i++) {
var obj = registeredSections[i];
var img;
img = document.getElementById('img_' + obj.headerId);
if (on && 'showListButton' == img.className) {
twistSection(img, obj.headerId, obj.mainTableId);
} else if (!on && 'hideListButton' == img.className) {
twistSection(img, obj.headerId, obj.mainTableId);
}
}
}
function toggleSection(headerId, on) {
var sectionHead = document.getElementById('head_' + headerId + '_j_id0_j_id4_myBlock');
var body = sectionHead.nextSibling;
var disp = on ? 'block' : 'none';
sectionHead.style.display = disp;
body.style.display = disp;
}
function registerTwistableSections_j_id0_j_id4_myBlock() {
registerTwistableSection('j_id0_j_id4_myBlock_j_id33', 'j_id0_j_id4_myBlock');
registerTwistableSection('j_id0_j_id4_myBlock_j_id108', 'j_id0_j_id4_myBlock');
}
registerTwistableSections_j_id0_j_id4_myBlock();
</script>
<div class="pbBody">
<div id="j_id0:j_id4:myBlock:j_id33">
<div data-twistyimgid="img_j_id0:j_id4:myBlock:j_id33" onclick="twistSection(this);" tabindex="0" style="cursor:pointer;" title="Hide Section - Service Request" class="pbSubheader brandTertiaryBgr first tertiaryPalette"
onkeypress="if (event.keyCode=='13')twistSection(this);"><img src="/VAMS/img/s.gif" alt="Hide Section - Service Request" class="hideListButton" id="img_j_id0:j_id4:myBlock:j_id33" name="Service Request">
<h3>Service Request</h3>
</div>
<div class="pbSubsection">
<table class="detailList" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td class="dataCol first " colspan="2">
<div id="j_id0:j_id4:myBlock:j_id33:j_id34">
<div class="pbSubsection">
<table class="detailList" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<th class="labelCol vfLabelColTextWrap first " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id34:fname"><span class="assistiveText">*</span>First Name</label></th>
<td class="data2Col first ">
<div class="requiredInput">
<div class="requiredBlock"></div><input class="slds-form-element" id="j_id0:j_id4:myBlock:j_id33:j_id34:fname" maxlength="255" name="j_id0:j_id4:myBlock:j_id33:j_id34:fname" size="20" type="text">
</div>
</td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id34:lname"><span class="assistiveText">*</span>Last Name</label></th>
<td class="data2Col ">
<div class="requiredInput">
<div class="requiredBlock"></div><input class="slds-form-element" id="j_id0:j_id4:myBlock:j_id33:j_id34:lname" maxlength="255" name="j_id0:j_id4:myBlock:j_id33:j_id34:lname" size="20" type="text">
</div>
</td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id34:email"><span class="assistiveText">*</span>Email</label></th>
<td class="data2Col ">
<div class="requiredInput">
<div class="requiredBlock"></div><input id="j_id0:j_id4:myBlock:j_id33:j_id34:email" maxlength="80" name="j_id0:j_id4:myBlock:j_id33:j_id34:email" size="20" type="text">
</div>
</td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2">Additional Email Addresses</label></th>
<td class="data2Col "><textarea id="j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2" maxlength="255" name="j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2"
onchange="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2', 255, 765, 'remaining', 'over limit', false);"
onclick="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2', 255, 765, 'remaining', 'over limit', false);"
onkeydown="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2', 255, 765, 'remaining', 'over limit', false);"
onkeyup="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2', 255, 765, 'remaining', 'over limit', false);"
onmousedown="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id34:ccemail2', 255, 765, 'remaining', 'over limit', false);" type="text" wrap="soft"
placeholder="Separate email addresses with a semicolon"></textarea></td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id34:phone">Phone Number</label></th>
<td class="data2Col "><input id="j_id0:j_id4:myBlock:j_id33:j_id34:phone" maxlength="40" name="j_id0:j_id4:myBlock:j_id33:j_id34:phone" onblur="formatPhone(this);" onkeydown="formatPhoneOnEnter(this, event);" size="20"
type="text" placeholder="Enter your 10-digit number"></td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id34:phoneext">Number Extension</label></th>
<td class="data2Col "><input id="j_id0:j_id4:myBlock:j_id33:j_id34:phoneext" maxlength="8" name="j_id0:j_id4:myBlock:j_id33:j_id34:phoneext" size="20" type="text"></td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap last " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id34:intphon">International Phone Number</label></th>
<td class="data2Col last "><input id="j_id0:j_id4:myBlock:j_id33:j_id34:intphon" maxlength="100" name="j_id0:j_id4:myBlock:j_id33:j_id34:intphon" size="20" type="text"></td>
</tr>
</tbody>
</table>
</div>
</div>
</td>
<td class="dataCol first " colspan="2">
<div id="j_id0:j_id4:myBlock:j_id33:j_id35">
<div class="pbSubsection">
<table class="detailList" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<th class="labelCol vfLabelColTextWrap first " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id35:provider">Provider/Partner</label></th>
<td class="data2Col first "><select id="j_id0:j_id4:myBlock:j_id33:j_id35:provider" name="j_id0:j_id4:myBlock:j_id33:j_id35:provider" class="slds-form-element" size="1" onchange="providerChanged();return false;">
<option value="">--None--</option>
<option value="Clinic">Clinic</option>
<option value="General Caller">General Caller</option>
<option value="Guest">Guest</option>
<option value="Jurisdiction">Jurisdiction</option>
<option value="Others">Others</option>
<option value="Recipient">Recipient</option>
</select></td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id35:providerother">Provider Other</label></th>
<td class="data2Col "><input id="j_id0:j_id4:myBlock:j_id33:j_id35:providerother" maxlength="255" name="j_id0:j_id4:myBlock:j_id33:j_id35:providerother" size="20" type="text" disabled=""
placeholder="Complete this field if Provider/Partner equals Other"></td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id35:jurisdiction"><span class="assistiveText">*</span>State/ Jurisdiction/ Organization</label></th>
<td class="data2Col ">
<font color="red">* </font><select id="j_id0:j_id4:myBlock:j_id33:j_id35:jurisdiction" name="j_id0:j_id4:myBlock:j_id33:j_id35:jurisdiction" class="slds-form-element" size="1">
<option value="">--None--</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="Bureau of Prisons">Bureau of Prisons</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="Dept of Defense">Dept of Defense</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indian Health Service">Indian Health Service</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York City">New York City</option>
<option value="New York State">New York State</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Philadelphia">Philadelphia</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="State Department">State Department</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="US Virgin Islands">US Virgin Islands</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virgin Islands">Virgin Islands</option>
<option value="Virginia">Virginia</option>
<option value="Washington State">Washington State</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select>
</td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id35:OtherState">Other/ State/ Country</label></th>
<td class="data2Col "><input id="j_id0:j_id4:myBlock:j_id33:j_id35:OtherState" maxlength="255" name="j_id0:j_id4:myBlock:j_id33:j_id35:OtherState" size="20" type="text"></td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail"><span class="assistiveText">*</span>Issue Detail</label></th>
<td class="data2Col ">
<div class="requiredInput">
<div class="requiredBlock"></div><textarea id="j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail" maxlength="32768" name="j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail" onblur="validateFields();"
onchange="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail', 32768, 0, 'remaining', 'over limit', false);"
onclick="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail', 32768, 0, 'remaining', 'over limit', false);"
onkeydown="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail', 32768, 0, 'remaining', 'over limit', false);"
onkeyup="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail', 32768, 0, 'remaining', 'over limit', false);"
onmousedown="handleTextAreaElementChangeWithByteCheck('j_id0:j_id4:myBlock:j_id33:j_id35:issuedetail', 32768, 0, 'remaining', 'over limit', false);" rows="3" type="text" wrap="soft"></textarea>
</div>
</td>
</tr>
<tr>
<th class="labelCol vfLabelColTextWrap last " scope="row"><label for="j_id0:j_id4:myBlock:j_id33:j_id35:pin">VAMS ID</label></th>
<td class="data2Col last "><input id="j_id0:j_id4:myBlock:j_id33:j_id35:pin" maxlength="50" name="j_id0:j_id4:myBlock:j_id33:j_id35:pin" size="20" type="text" value="VAMS-"></td>
</tr>
</tbody>
</table>
</div>
</div>
</td>
</tr>
<tr>
<td class="dataCol last " colspan="2">
<br> *Indicates a required field.<br><br> Review form to ensure no PII/PHI (Personally Identifiable Information/Personal Health Information) is included prior to submitting.<br>
</td>
<td class="labelCol empty"> </td>
<td class="dataCol empty"> </td>
</tr>
</tbody>
</table>
</div>
</div>
<div id="j_id0:j_id4:myBlock:j_id108">
<div data-twistyimgid="img_j_id0:j_id4:myBlock:j_id108" onclick="twistSection(this);" tabindex="0" style="cursor:pointer;" title="Hide Section - Upload file" class="pbSubheader brandTertiaryBgr tertiaryPalette"
onkeypress="if (event.keyCode=='13')twistSection(this);"><img src="/VAMS/img/s.gif" alt="Hide Section - Upload file" class="hideListButton" id="img_j_id0:j_id4:myBlock:j_id108" name="Upload file">
<h3>Upload file</h3>
</div>
<div class="pbSubsection">
<table class="detailList" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td class="data2Col first " colspan="2">
<input accept="" accesskey="" alt="" class="" dir="" id="j_id0:j_id4:myBlock:j_id108:j_id109" lang="" name="j_id0:j_id4:myBlock:j_id108:j_id109:inputFile:file" onblur="" onchange="" onclick="" ondblclick="" onfocus=""
onkeydown="" onkeypress="" onkeyup="" onmousedown="" onmousemove="" onmouseout="" onmouseover="" size="" style="" tabindex="" title="" type="file">
</td>
</tr>
<tr>
<td class="data2Col last " colspan="2"> Only one file upload allowed (10mb maximum size). Create a zip file to upload multiple files. <br></td>
</tr>
</tbody>
</table>
</div>
</div>
<br>
<br>
<div style="text-align:center"> <input type="submit" name="j_id0:j_id4:myBlock:j_id116" value="Submit" onclick="addSpinner();" style="width:100px;" class="btn slds-button slds-button--brand">
<br>
<br>
</div>
<br>
</div>
<div class="pbFooter secondaryPalette">
<div class="bg"></div>
</div>
</div>
</div>
</div>
<div id="j_id0:j_id4:j_id121"></div>
</form>Text Content
Loading VAMS (Vaccine Administration Management System) New Service Request SERVICE REQUEST *First Name *Last Name *Email Additional Email AddressesPhone NumberNumber ExtensionInternational Phone Number Provider/Partner --None-- Clinic General Caller Guest Jurisdiction Others Recipient Provider Other*State/ Jurisdiction/ Organization* --None-- Alabama Alaska Arizona Arkansas Bureau of Prisons California Colorado Connecticut Delaware Dept of Defense District of Columbia Florida Georgia Hawaii Idaho Illinois Indian Health Service Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York City New York State North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Philadelphia Puerto Rico Rhode Island South Carolina South Dakota State Department Tennessee Texas US Virgin Islands Utah Vermont Virgin Islands Virginia Washington State West Virginia Wisconsin Wyoming Other/ State/ Country*Issue Detail VAMS ID *Indicates a required field. Review form to ensure no PII/PHI (Personally Identifiable Information/Personal Health Information) is included prior to submitting. UPLOAD FILE Only one file upload allowed (10mb maximum size). Create a zip file to upload multiple files.