redcap.ohiohealth.com
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URL:
https://redcap.ohiohealth.com/surveys/?s=484RXNAAHK
Submission: On February 06 via api from US — Scanned from DE
Submission: On February 06 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: form — POST /surveys/index.php?s=484RXNAAHK
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style="display:none;" data-rc-lang="data_entry_203">Value removed!</span>
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<div data-mlm-field="first_name" data-mlm-type="label"> First Name</div>
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<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-required="true" aria-labelledby="label-first_name" class="x-form-text x-form-field " type="text" name="first_name" value="" tabindex="0"></span>
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<div data-mlm-field="last_name" data-mlm-type="label"> Last Name</div>
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<div data-mlm-field="email" data-mlm-type="label"> Email Address</div>
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<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-required="true" aria-labelledby="label-email" class="x-form-text x-form-field " type="text" name="email" value=""
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<div data-mlm-field="employer" data-mlm-type="label"> Employer</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
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<div data-mlm-field="signature" data-mlm-type="label"> Please sign your name</div>
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<div data-mlm-field="date" data-mlm-type="label"> Date</div>
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</form>Text Content
The code block below illustrates how one might use # and // as comments in your
logic and calculations.
# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,
// This comment can explain what the next line does.
[score] * [factor],
// Return '0' if the condition is False.
0
)
Working...
0% means
50% means
100% means
This value you provided is not a number. Please try again.
This value you provided is not an integer. Please try again.
The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to
9-digit number, excluding leading zeros). Please try again.
The value you provided must be within the suggested range
The value you provided is outside the suggested range
This value is admissible, but you may wish to double check it.
The value entered must be a time value in the following format HH:MM within the
range 00:00-23:59 (e.g., 04:32 or 23:19).
This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it
now.
This field must be a 10 digit U.S. phone number (like 415 555 1212). Please
re-enter it now.
This field must be a valid email address (like joe@user.com). Please re-enter it
now.
The value you provided could not be validated because it does not follow the
expected format. Please try again.
Required format:
3nEhSVUcdWXy6VPxcXLzA8FzZoAFXzPnd955WhQhnkS2BkRrnyfwjNJASNpL7
EMPLOYER SOLUTIONS VIRTUAL GROUP FITNESS WAIVER
A A A
Please read the following waiver of liability prior to participating in the
OhioHealth virtual group fitness classes and sign and date below.
The undersigned (collectively referred to herein as "me", "my", or "I") desires
to participate in exercise or fitness activities led by employees of OhioHealth
Corporation ("Program"). I am participating in this Program with the
understanding and on the condition that:
* I will abide by all requests of Program staff and any policies, procedures,
or regulations that may be posted or provided by Program from time to time.
* I am voluntarily participating in the Program. As a condition of
participation, I represent and warrant that I am in good physical condition
and I am able to participate in the Program and utilize the equipment and
services associated with the Program.
* I have been advised to consult my physician prior to starting the Program. If
I choose to engage in fitness activities, all physical activity and
participation in activities offered through the Program are undertaken by me
at my own risk. I have read and agree to the below Waiver of Liability.
* I acknowledge that at-home/virtual supervision is different than in-person
training/supervision. I understand that all exercise will be undertaken by me
at my sole risk.
* Program does not warrant the safety of (and is released from liability and/or
negligence for): (i) all at-home exercise equipment or surroundings; and (ii)
the effectiveness (e.g., quality of video/audio, free from bugs/interruption)
and/or security of any at-home technology, including, but not limited to,
video or Internet ("Technology").
* There are no warranties or representations, express or implied, about the
Program, Program instruction and literatures, or efficacy of the Program for
achievement of any specific goals, with respect to any techniques or
recommendations described or taught through the Program.
WARNING: Do not participate in at-home/virtual training if prone to seizures.
Flashing lights and rapid imagery changes may occur. Motion sickness may be
experienced.
Waiver of Liability
UNDER THE FOLLOWING PROVISION THE PARTICIPANT SIGNING BELOW IS RELEASING CERTAIN
LEGAL RIGHTS. PLEASE READ THIS LANGUAGE CAREFULLY.
Any exercise or fitness activity or participation in activities offered through
the Program and its associated services, including participation though
Technology, has an inherent risk of personal injury or property damage. This may
include, without limitation, damages or injuries that may result from:
(a) Exercise or exercise-induced illness or injuries, including but not limited
to heart attack, stroke, heart stress, sprains, broken bones, and muscle, joint,
ligament, back, and neck injuries. Such injuries may arise from participation in
supervised or unsupervised activities or programs within or outside of the
Program and/or Technology, to the extent sponsored or endorsed by the Program.
Further, such injuries may occur when an exercise is properly or improperly
performed or due to malfunction or misuse of Technology.
(b) Injuries that arise from my failure to seek prior physician consult,
evaluation, and approval to engage in a program;
(c) Slips, falls, and other accidental injuries sustained on or as a result of
the location and/or equipment and/or Technology used by me to participate in the
Program, such as machines, fixtures, weights, treadmills, bikes, and exercise
bands, my physical surroundings, or service problems or malfunctions;
(d) Injuries sustained as a result of the acts or omissions of myself or other
Program participants; or
(e) Damages to or loss or my property used by me in connection with my
participation in activities through the Program or use of Technology.
Program will not be responsible for these or any other injuries or damages I may
sustain in connection with my use of the Technology or participation in
activities offered by the Program. As a condition of such use and participation,
I agree that my use of the Technology or participation in activities through the
Program will be undertaken by me at my sole risk and responsibility, and without
any liability to me on the part of Program, its owners, parent, subsidiary, or
affiliate organizations, or their respective employees, instructors, managers,
agent, officers, or directors (collectively the "Program representatives"). I
accept full responsibility for my use, as well as the use by any other person
under my membership, of any and all equipment and fixtures as well as any
programs and activities provided by Program. I, on behalf of myself and my
executors, administrators, heirs, representatives, assigns, and successors do
hereby expressly forever release, hold harmless and discharge Program and all
Program representatives from all direct or indirect injuries (including death),
damages, expenses, costs, claims, demands, liabilities, or legal or equitable
actions or causes of actions of any kind, that result from my use or the use by
any other person under use of the Technology or participation in activities
through the Program, including, without limitation, any acts of active or
passive negligence on the part of the Program or any Program representatives, or
the active or passive negligence or intentional misconduct of other participants
in the Program. I agree that this release and waiver of liability covers
activities and injuries, as described herein, that may result from supervised or
unsupervised activities. I hereby further agree to indemnify and hold harmless
OhioHealth and the Program representatives from any and all such Claims.
I acknowledge that I have fully read and reviewed the foregoing document, that I
fully understand its contents, and that all questions about this document, if
any, have been answered.
Employee Waiver
By signing below, I declare that I am a voluntary participant in my employer's
off duty sponsored recreation or fitness activity and that participation in this
activity is outside the scope of my employment. I waive and relinquish all
rights to Workers' Compensation benefits under Chapter 4123 of the Revised Code
of any injury or disability incurred while participating in the activity. I
assume any and all risk of injury or damages incurred from participating in this
activity. To the extent that a medical clearance is needed, I have been advised
to consult my physician and obtain written permission prior to commencing this
activity. Should I experience any unusual symptoms during the activity, I will
cease participation and inform the Program representatives of the symptoms.
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1)
First Name
* must provide value
2)
Last Name
* must provide value
3)
Email Address
* must provide value
4)
Employer
* must provide value
5)
Please sign your name
* must provide value
( MB)
Add signature
6)
Date
* must provide value
NowM-D-Y H:M:S
Submit
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To save your responses and end the survey, click the 'End Survey' button below.
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survey, click the 'Return and Edit Response' button.
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