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Form analysis
1 forms found in the DOM

POST /HR/ContingentWorker/VerifyAuthentication

<form action="/HR/ContingentWorker/VerifyAuthentication" method="post"><input data-val="true" data-val-required="The RequestId field is required." id="RequestId" name="RequestId" type="hidden" value="5727c243-7c3d-445c-83ab-fbc89dfb8aa9">
  <div class="row">
    <div class="col-xs-12">
      <h4><u>Step 1:</u> Please enter the requested information to verify that the Contingent Worker access request is authentic and that you have permission to complete the setup process.</h4>
    </div>
  </div>
  <br>
  <div class="row">
    <div class="col-xs-12" style="background-color:lightgray;border-radius:3px 4px;height:1%;display:none;">
      <br>
      <p style="font-size:16px;"><b><span style="text-decoration:underline;">NOTE:</span> By completing this access authentication you are agreeing to the Select Medical Information Security Policy (ISP)<a href="#">Review the policy.</a></b></p>
      <br>
    </div>
  </div>
  <div class="row">
    <div class="col-md-1"></div>
    <div class="col-md-11">
      <div class="form-group sm-title">
        <h4 style="text-decoration:underline">Contingent Worker Personal Information</h4>
      </div>
      <div class="form-group">
        <span class="field-validation-valid" data-valmsg-for="error" data-valmsg-replace="true"></span>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col-md-1"></div>
    <div class="col-md-2">
      <div class="form-group">
        <label>Last Name:&nbsp;</label>
      </div>
    </div>
    <div class="col-md-3">
      <div class="form-group">
        <input class="form-control lg" data-val="true" data-val-required="The LastName field is required." id="LastName" name="LastName" type="text" value="">
      </div>
    </div>
  </div>
  <div id="divBirthDate" class="row">
    <div class="col-md-1"></div>
    <div class="col-md-2">
      <div class="form-group">
        <label>Date of Birth:&nbsp;</label>
      </div>
    </div>
    <div class="col-md-3">
      <div class="form-group">
        <input class="form-control lg" data-val="true" data-val-date="The field DateOfBirth must be a date." data-val-required="The DateOfBirth field is required." id="DateOfBirth" name="DateOfBirth" placeholder="MM/DD/YYYY" type="text" value="">
      </div>
    </div>
  </div>
  <div class="row sm-button-container">
    <div class="col-md-1"></div>
    <div class="col-md-11">
      <div class="form-group">
        <input type="submit" value="Verify Access" class="btn btn-primary" style="max-width:300px;">
      </div>
    </div>
  </div>
</form>

Text Content

STEP 1: PLEASE ENTER THE REQUESTED INFORMATION TO VERIFY THAT THE CONTINGENT
WORKER ACCESS REQUEST IS AUTHENTIC AND THAT YOU HAVE PERMISSION TO COMPLETE THE
SETUP PROCESS.





NOTE: By completing this access authentication you are agreeing to the Select
Medical Information Security Policy (ISP)Review the policy.


CONTINGENT WORKER PERSONAL INFORMATION


Last Name: 

Date of Birth: 



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