www.bloombergsurvey.com Open in urlscan Pro
44.199.149.132  Public Scan

Form analysis
1 forms found in the DOM

POST https://www.bloombergsurvey.com/api/v1/

<form role="form" id="alpaca2" data-alpaca-form-id="alpaca2" action="https://www.bloombergsurvey.com/api/v1/" method="post" class="alpaca-form">
  <div class="alpaca-field alpaca-field-object alpaca-optional alpaca-create alpaca-top" data-alpaca-field-id="alpaca1" data-alpaca-field-path="/" data-alpaca-field-name="">
    <legend class="alpaca-container-label"> Help Bloomberg News cover the coronavirus story </legend>
    <p class="alpaca-helper help-block ">
      <i class="alpaca-icon-16 glyphicon glyphicon-info-sign"></i> Our reporters around the globe are covering the impact of the coronavirus. If you have information to share and want to get in touch, the form below is a good way to get it to the
      right journalists. We won’t publish what you share without verifying it first, and we won't publish your name without your permission.
    </p>
    <div class="alpaca-container alpaca-vertical alpaca-container-has-items" data-alpaca-container-item-count="12">
      <div class="alpaca-container-item alpaca-container-item-first" data-alpaca-container-item-index="0" data-alpaca-container-item-name="name" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-text alpaca-optional alpaca-autocomplete" data-alpaca-field-id="alpaca3" data-alpaca-field-path="/name" data-alpaca-field-name="name">
          <label class="control-label alpaca-control-label" for="alpaca3">Your name:</label>
          <input type="text" id="alpaca3" name="name" class="alpaca-control form-control" autocomplete="off">
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="1" data-alpaca-container-item-name="aboutSelf" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-radio alpaca-optional" data-alpaca-field-id="alpaca10" data-alpaca-field-path="/aboutSelf" data-alpaca-field-name="aboutSelf">
          <label class="control-label alpaca-control-label" for="alpaca10">Tell us about yourself:</label>
          <div class="radio alpaca-control" name="aboutSelf" style="display: block;">
            <label>
              <input type="radio" name="aboutSelf" value="Medical provider (doctor, nurse, etc.)" class="">Medical provider (doctor, nurse, etc.) </label>
          </div>
          <div class="radio alpaca-control" name="aboutSelf" style="display: block;">
            <label>
              <input type="radio" name="aboutSelf" value="Non-clinical employee in health-care industry" class="">Non-clinical employee in health-care industry </label>
          </div>
          <div class="radio alpaca-control" name="aboutSelf" style="display: block;">
            <label>
              <input type="radio" name="aboutSelf" value="Public health agency employee" class="">Public health agency employee </label>
          </div>
          <div class="radio alpaca-control" name="aboutSelf" style="display: block;">
            <label>
              <input type="radio" name="aboutSelf" value="Other government employee" class="">Other government employee </label>
          </div>
          <div class="radio alpaca-control" name="aboutSelf" style="display: block;">
            <label>
              <input type="radio" name="aboutSelf" value="Patient or family member of a patient" class="">Patient or family member of a patient </label>
          </div>
          <div class="radio alpaca-control" name="aboutSelf" style="display: block;">
            <label>
              <input type="radio" name="aboutSelf" value="In a business affected by the pandemic" class="">In a business affected by the pandemic </label>
          </div>
          <div class="radio alpaca-control" name="aboutSelf" style="display: block;">
            <label>
              <input type="radio" name="aboutSelf" value="Other (please specify)" class="">Other (please specify) </label>
          </div>
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="2" data-alpaca-container-item-name="aboutSelfOther" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-conditionalField alpaca-optional alpaca-autocomplete conditionalField" data-alpaca-field-id="alpaca14" data-alpaca-field-path="/aboutSelfOther" data-alpaca-field-name="aboutSelfOther"
          style="display: none;">
          <label class="control-label alpaca-control-label" for="alpaca14">Other profession:</label>
          <input type="text" id="alpaca14" name="aboutSelfOther" class="alpaca-control form-control" autocomplete="off">
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="3" data-alpaca-container-item-name="country" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-conditionalFieldSelect alpaca-optional" data-alpaca-field-id="alpaca9" data-alpaca-field-path="/country" data-alpaca-field-name="country">
          <label class="control-label alpaca-control-label" for="alpaca9">Which country are you located in:</label>
          <select id="alpaca9" name="country" class="alpaca-control form-control">
            <option value="">Select country</option>
            <option value="United States">United States</option>
            <option value="Argentina">Argentina</option>
            <option value="Australia">Australia</option>
            <option value="Austria">Austria</option>
            <option value="Azerbaijan">Azerbaijan</option>
            <option value="Bahrain">Bahrain</option>
            <option value="Bangladesh">Bangladesh</option>
            <option value="Belgium">Belgium</option>
            <option value="Bermuda">Bermuda</option>
            <option value="Brazil">Brazil</option>
            <option value="Bulgaria">Bulgaria</option>
            <option value="Canada">Canada</option>
            <option value="Chile">Chile</option>
            <option value="China">China</option>
            <option value="Colombia">Colombia</option>
            <option value="Costa Rica">Costa Rica</option>
            <option value="Cuba">Cuba</option>
            <option value="Czech Republic">Czech Republic</option>
            <option value="Democratic Republic of the Congo">Democratic Republic of the Congo</option>
            <option value="Denmark">Denmark</option>
            <option value="Dominican Republic">Dominican Republic</option>
            <option value="Ecuador ">Ecuador </option>
            <option value="Egypt">Egypt</option>
            <option value="Finland">Finland</option>
            <option value="France">France</option>
            <option value="Germany">Germany</option>
            <option value="Ghana">Ghana</option>
            <option value="Greece">Greece</option>
            <option value="Guatemala">Guatemala</option>
            <option value="Hong Kong">Hong Kong</option>
            <option value="Hungary">Hungary</option>
            <option value="India">India</option>
            <option value="Indonesia">Indonesia</option>
            <option value="Ireland">Ireland</option>
            <option value="Israel">Israel</option>
            <option value="Italy">Italy</option>
            <option value="Japan">Japan</option>
            <option value="Korea (South)">Korea (South)</option>
            <option value="Latvia">Latvia</option>
            <option value="Luxembourg">Luxembourg</option>
            <option value="Macau">Macau</option>
            <option value="Malaysia">Malaysia</option>
            <option value="Mexico">Mexico</option>
            <option value="Netherlands">Netherlands</option>
            <option value="New Zealand">New Zealand</option>
            <option value="Nigeria">Nigeria</option>
            <option value="Norway">Norway</option>
            <option value="Pakistan">Pakistan</option>
            <option value="Panama">Panama</option>
            <option value="Peru">Peru</option>
            <option value="Philippines">Philippines</option>
            <option value="Poland">Poland</option>
            <option value="Portugal">Portugal</option>
            <option value="Qatar">Qatar</option>
            <option value="Romania">Romania</option>
            <option value="Russian Federation">Russian Federation</option>
            <option value="Saudi Arabia">Saudi Arabia</option>
            <option value="Singapore">Singapore</option>
            <option value="South Africa">South Africa</option>
            <option value="Spain">Spain</option>
            <option value="Sri Lanka">Sri Lanka</option>
            <option value="Sweden">Sweden</option>
            <option value="Switzerland">Switzerland</option>
            <option value="Syria">Syria</option>
            <option value="Taiwan">Taiwan</option>
            <option value="Thailand">Thailand</option>
            <option value="Turkey">Turkey</option>
            <option value="United Arab Emirates">United Arab Emirates</option>
            <option value="United Kingdom">United Kingdom</option>
            <option value="Venezuela">Venezuela</option>
            <option value="Vietnam">Vietnam</option>
            <option value="Other (please specify)">Other (please specify)</option>
          </select>
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="4" data-alpaca-container-item-name="countryOther" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-conditionalField alpaca-optional alpaca-autocomplete conditionalField" data-alpaca-field-id="alpaca13" data-alpaca-field-path="/countryOther" data-alpaca-field-name="countryOther"
          style="display: none;">
          <label class="control-label alpaca-control-label" for="alpaca13">Other country:</label>
          <input type="text" id="alpaca13" name="countryOther" class="alpaca-control form-control" autocomplete="off">
          <p class="help-block ">
            <i class="glyphicon glyphicon-info-sign"></i> Please specify a country
          </p>
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="5" data-alpaca-container-item-name="state" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-conditionalFieldSelect alpaca-optional conditionalField" data-alpaca-field-id="alpaca6" data-alpaca-field-path="/state" data-alpaca-field-name="state" style="display: none;">
          <label class="control-label alpaca-control-label" for="alpaca6">U.S. state:</label>
          <select id="alpaca6" name="state" class="alpaca-control form-control">
            <option value="">Select state</option>
            <option value="Alabama">Alabama</option>
            <option value="Alaska">Alaska</option>
            <option value="Arizona">Arizona</option>
            <option value="Arkansas">Arkansas</option>
            <option value="California">California</option>
            <option value="Colorado">Colorado</option>
            <option value="Connecticut">Connecticut</option>
            <option value="Delaware">Delaware</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="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">New York</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="Rhode Island">Rhode Island</option>
            <option value="South Carolina">South Carolina</option>
            <option value="South Dakota">South Dakota</option>
            <option value="Tennessee">Tennessee</option>
            <option value="Texas">Texas</option>
            <option value="Utah">Utah</option>
            <option value="Vermont">Vermont</option>
            <option value="Virginia">Virginia</option>
            <option value="Washington">Washington</option>
            <option value="Washington D.C.">Washington D.C.</option>
            <option value="West Virginia">West Virginia</option>
            <option value="Wisconsin">Wisconsin</option>
            <option value="Wyoming">Wyoming</option>
          </select>
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="6" data-alpaca-container-item-name="topic" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-checkbox alpaca-optional" data-alpaca-field-id="alpaca7" data-alpaca-field-path="/topic" data-alpaca-field-name="topic">
          <label class="control-label alpaca-control-label" for="alpaca7">What topic do you want to share information about? (check all)</label>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="0" data-checkbox-value="Spread of the virus" class=""> Spread of the virus </label>
          </div>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="1" data-checkbox-value="Testing" class=""> Testing </label>
          </div>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="2" data-checkbox-value="Drug or vaccine development" class=""> Drug or vaccine development </label>
          </div>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="3" data-checkbox-value="Hospital conditions/capacity" class=""> Hospital conditions/capacity </label>
          </div>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="4" data-checkbox-value="Protective equipment and other supplies" class=""> Protective equipment and other supplies </label>
          </div>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="5" data-checkbox-value="Government response" class=""> Government response </label>
          </div>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="6" data-checkbox-value="Economic impact" class=""> Economic impact </label>
          </div>
          <div class="alpaca-control checkbox" name="topic">
            <label>
              <input type="checkbox" data-checkbox-index="7" data-checkbox-value="Other (please specify)" class=""> Other (please specify) </label>
          </div>
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="7" data-alpaca-container-item-name="topicOther" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-conditionalField alpaca-optional alpaca-autocomplete conditionalField" data-alpaca-field-id="alpaca11" data-alpaca-field-path="/topicOther" data-alpaca-field-name="topicOther"
          style="display: none;">
          <label class="control-label alpaca-control-label" for="alpaca11">Other topic:</label>
          <input type="text" id="alpaca11" name="topicOther" class="alpaca-control form-control" autocomplete="off">
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="8" data-alpaca-container-item-name="information" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-textarea alpaca-optional alpaca-autocomplete" data-alpaca-field-id="alpaca12" data-alpaca-field-path="/information" data-alpaca-field-name="information">
          <label class="control-label alpaca-control-label" for="alpaca12">What information do you want to share?</label>
          <textarea id="alpaca12" rows="5" cols="40" name="information" class="alpaca-control form-control" autocomplete="off"></textarea>
          <p class="help-block ">
            <i class="glyphicon glyphicon-info-sign"></i> Please be as specific and as concise as possible. (No PR pitches please.)
          </p>
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="9" data-alpaca-container-item-name="contact" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-textarea alpaca-optional alpaca-autocomplete" data-alpaca-field-id="alpaca8" data-alpaca-field-path="/contact" data-alpaca-field-name="contact">
          <label class="control-label alpaca-control-label" for="alpaca8">What’s the best way to follow up with you? (We won’t publish your contact information, and we won’t publish your name without your permission. Reporters may follow-up to verify
            information or get more details.)</label>
          <textarea id="alpaca8" rows="5" cols="40" name="contact" class="alpaca-control form-control" autocomplete="off"></textarea>
        </div>
      </div>
      <div class="alpaca-container-item" data-alpaca-container-item-index="10" data-alpaca-container-item-name="email" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-email alpaca-optional alpaca-autocomplete" data-alpaca-field-id="alpaca4" data-alpaca-field-path="/email" data-alpaca-field-name="email">
          <label class="control-label alpaca-control-label" for="alpaca4">Email:</label>
          <input type="email" id="alpaca4" name="email" class="alpaca-control form-control" autocomplete="off">
        </div>
      </div>
      <div class="alpaca-container-item alpaca-container-item-last" data-alpaca-container-item-index="11" data-alpaca-container-item-name="phone" data-alpaca-container-item-parent-field-id="alpaca1">
        <div class="form-group alpaca-field alpaca-field-text alpaca-optional alpaca-autocomplete" data-alpaca-field-id="alpaca5" data-alpaca-field-path="/phone" data-alpaca-field-name="phone">
          <label class="control-label alpaca-control-label" for="alpaca5">Phone:</label>
          <input type="text" id="alpaca5" name="phone" class="alpaca-control form-control" autocomplete="off">
        </div>
      </div>
    </div>
  </div>
  <div class="alpaca-form-buttons-container">
    <button data-key="submit" type="submit" class="alpaca-form-button alpaca-form-button-submit btn btn-default">Submit Form<span class="click-target"></span></button>
  </div>
</form>

Text Content

Bloomberg
Surveys
Help Bloomberg News cover the coronavirus story

Our reporters around the globe are covering the impact of the coronavirus. If
you have information to share and want to get in touch, the form below is a good
way to get it to the right journalists. We won’t publish what you share without
verifying it first, and we won't publish your name without your permission.

Your name:
Tell us about yourself:
Medical provider (doctor, nurse, etc.)
Non-clinical employee in health-care industry
Public health agency employee
Other government employee
Patient or family member of a patient
In a business affected by the pandemic
Other (please specify)
Other profession:
Which country are you located in: Select country United States Argentina
Australia Austria Azerbaijan Bahrain Bangladesh Belgium Bermuda Brazil Bulgaria
Canada Chile China Colombia Costa Rica Cuba Czech Republic Democratic Republic
of the Congo Denmark Dominican Republic Ecuador Egypt Finland France Germany
Ghana Greece Guatemala Hong Kong Hungary India Indonesia Ireland Israel Italy
Japan Korea (South) Latvia Luxembourg Macau Malaysia Mexico Netherlands New
Zealand Nigeria Norway Pakistan Panama Peru Philippines Poland Portugal Qatar
Romania Russian Federation Saudi Arabia Singapore South Africa Spain Sri Lanka
Sweden Switzerland Syria Taiwan Thailand Turkey United Arab Emirates United
Kingdom Venezuela Vietnam Other (please specify)
Other country:

Please specify a country

U.S. state: Select state Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas
Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi
Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York
North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington
Washington D.C. West Virginia Wisconsin Wyoming
What topic do you want to share information about? (check all)
Spread of the virus
Testing
Drug or vaccine development
Hospital conditions/capacity
Protective equipment and other supplies
Government response
Economic impact
Other (please specify)
Other topic:
What information do you want to share?

Please be as specific and as concise as possible. (No PR pitches please.)

What’s the best way to follow up with you? (We won’t publish your contact
information, and we won’t publish your name without your permission. Reporters
may follow-up to verify information or get more details.)
Email:
Phone:
Submit Form
Terms of Service Trademarks Privacy Policy ©2020 Bloomberg L.P. All Rights
Reserved