survey.health.mil Open in urlscan Pro
214.79.252.13  Public Scan

Form analysis
7 forms found in the DOM

<form>
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-person"></i> </span>
      </div>
      <input id="login-username" class="form-control skip-surv-valid" placeholder="Email Address" type="email">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-lock-locked"></i> </span>
      </div>
      <input id="login-password" class="form-control" placeholder="******" type="password">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <p class="text-center text-danger" id="incorrect-login" style="display:none">Incorrect email or PIN</p>
  <p class="text-center text-danger" id="expired-login" style="display:none"><span id="expired-login1">This token recently expired</span><span id="expired-login2" style="display: block;"></span></p>
  <div class="form-group">
    <button type="submit" id="btn-login" class="btn btn-primary btn-block"> Login </button>
  </div> <!-- form-group// -->
  <div class="form-group">
    <button type="submit" id="btn-trusted-register" style="display:none" class="btn btn-primary btn-block"> Register with Token </button>
  </div> <!-- form-group// -->
</form>

---

<form>
  <div class="form-group register-trusted-token-container" style="display:none">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-lock-locked"></i> </span>
      </div>
      <input id="register-token" name="register-token" class="form-control skip-surv-valid" placeholder="Registration Token *" type="tel"> <br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-token"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-person"></i> </span>
      </div>
      <input id="register-firstname" name="register-firstname" class="form-control skip-surv-valid" placeholder="First Name *" type="text" data-required-msg="Please enter First Name" required="required"> <br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-firstname"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-person"></i> </span>
      </div>
      <input id="register-lastname" name="register-lastname" class="form-control skip-surv-valid" placeholder="Last Name *" type="text" data-required-msg="Please enter Last Name" required="required"> <br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-lastname"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-envelope-closed"></i> </span>
      </div>
      <input id="register-email" name="register-email" class="form-control skip-surv-valid" placeholder="Primary Email Address *" type="email" data-email-msg="Please enter a valid email address" data-required-msg="Please enter a valid email address"
        required="required"> <br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-email"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-envelope-closed"></i> </span>
      </div>
      <input id="register-altemail" name="register-altemail" class="form-control skip-surv-valid" placeholder="Secondary Email Address" type="email" data-email-msg="Please enter a valid email address"><br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-altemail"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-phone"></i> </span>
      </div>
      <span class="k-widget k-maskedtextbox form-control skip-surv-valid" style=""><input id="register-phone" name="register-phone" class="form-control skip-surv-valid k-textbox" placeholder="Primary Phone Number *" type="tel"
          data-role="maskedtextbox" autocomplete="off" style="width: 100%;"><span class="k-icon k-i-warning"></span></span><br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-phone"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-globe"></i> </span>
      </div>
      <input id="register-edipi" name="register-edipi" class="form-control skip-surv-valid" placeholder="DoD ID Number (EDIPN) *" type="tel"><br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-edipi"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-person"></i> </span>
      </div>
      <span class="k-widget k-datepicker k-header form-control skip-surv-valid" style=""><span class="k-picker-wrap k-state-default"><input id="register-dob" name="register-dob" class="form-control skip-surv-valid k-input"
            placeholder="Date of Birth *" type="text" data-role="datepicker" role="combobox" aria-expanded="false" aria-owns="register-dob_dateview" autocomplete="off" aria-disabled="false" style="width: 100%;"><span unselectable="on"
            class="k-select" aria-label="select" role="button" aria-controls="register-dob_dateview"><span class="k-icon k-i-calendar"></span></span></span></span><br>
    </div> <!-- input-group.// -->
    <span class="k-invalid-msg" data-for="register-dob"></span>
  </div> <!-- form-group// -->
  <div class="form-group">
    <label id="register-failed" style="display:none;color:red">There was an issue with your registration. Please try again or contact your facility.</label>
  </div> <!-- form-group// -->
  <div class="form-group">
    <button type="button" id="btn-register" class="btn btn-primary btn-block">Register</button>
  </div> <!-- form-group// -->
  <div class="form-group">
    <button type="button" id="btn-register-scan" class="btn btn-primary btn-block" style="display: block;">Scan My CAC</button>
  </div>
</form>

---

<form id="updateProfileForm" data-role="validator" novalidate="novalidate">
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-person"></i> </span>
      </div>
      <input id="emailPrimary" name="emailPrimary" class="form-control" placeholder="Primary Email Address" type="email"> <br>
      <span class="k-invalid-msg" data-for="emailPrimary"></span>
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-person"></i> </span>
      </div>
      <input id="emailSecondary" name="emailSecondary" class="form-control" placeholder="Secondary Email Address" type="email"><br>
      <span class="k-invalid-msg" data-for="emailSecondary"></span>
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <hr>
  <p class="text-center">Please update your primary and secondary phone numbers if they have changed</p>
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-phone"></i> </span>
      </div>
      <span class="k-widget k-maskedtextbox form-control" style=""><input id="phonePrimary" name="phonePrimary" class="form-control k-textbox" placeholder="Primary Phone Number" type="tel" data-role="maskedtextbox" autocomplete="off"
          style="width: 100%;"><span class="k-icon k-i-warning"></span></span><br>
      <span class="k-invalid-msg" data-for="phonePrimary"></span>
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-phone"></i> </span>
      </div>
      <span class="k-widget k-maskedtextbox form-control" style=""><input id="phoneSecondary" name="phoneSecondary" class="form-control k-textbox" placeholder="Secondary Phone Number" type="tel" data-role="maskedtextbox" autocomplete="off"
          style="width: 100%;"><span class="k-icon k-i-warning"></span></span><br>
      <span class="k-invalid-msg" data-for="phoneSecondary"></span>
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <button type="submit" id="btn-ContactUpdate" class="btn btn-primary btn-block">Update Profile or Continue to Surveys</button>
  </div> <!-- form-group// -->
</form>

---

<form>
  <div class="py-4 text-center form-buttons">
    <a href="#" id="btn-page-prev" style="display:none" class="btn btn-secondary btn-lg" role="button" aria-pressed="true">Previous Page</a>
    <a href="#" id="btn-page-next" style="display:none" class="btn btn-primary btn-lg" role="button" aria-pressed="true">Next Page</a>
    <button type="button" id="button-submit" style="display:none" class="btn btn-primary btn-lg" role="button" aria-pressed="true">Submit</button>
  </div>
  <div class="text-center form-buttons" style="display:none" id="control-buttons">
    <a style="display:none" href="#" class="btn btn-secondary btn-lg button-partialsave" role="button" aria-pressed="true">Save and Continue Later</a>
    <a href="#" id="button-cancel" class="btn btn-secondary btn-lg" role="button" aria-pressed="true">Cancel</a>
  </div>
</form>

---

<form>
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-lock-locked"></i> </span>
      </div>
      <input id="login-window-password" class="form-control" placeholder="*************" type="password">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <p class="text-center text-danger" id="incorrect-login-window" style="display:none">Incorrect password</p>
  <div class="form-group">
    <button type="submit" id="btn-login-window" style="width:94%" class="btn btn-primary btn-block"> Login </button>
  </div> <!-- form-group// -->
  <p class="text-center"><a href="#" class="btn">Forgot password?</a></p>
</form>

---

<form>
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-lock-locked"></i> </span>
      </div>
      <input id="change-password" class="form-control" placeholder="*************" type="password">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-lock-locked"></i> </span>
      </div>
      <input id="change-password-confirm" class="form-control" placeholder="*************" type="password">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <button type="submit" style="width:94%" id="btn-change" class="btn btn-primary btn-block"> Update </button>
  </div> <!-- form-group// -->
</form>

---

<form>
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-lock-locked"></i> </span>
      </div>
      <input id="set-password" class="form-control" placeholder="*************" type="password">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-lock-locked"></i> </span>
      </div>
      <input id="set-password-confirm" class="form-control" placeholder="*************" type="password">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <div class="input-group">
      <div class="input-group-prepend">
        <span class="input-group-text" style="width: 40px"> <i class="oi oi-phone"></i> </span>
      </div>
      <input id="set-password-phone" class="form-control" placeholder="###-###-####" type="tel">
    </div> <!-- input-group.// -->
  </div> <!-- form-group// -->
  <div class="form-group">
    <button type="submit" style="width:94%" id="btn-set" class="btn btn-primary btn-block"> Set Password </button>
  </div> <!-- form-group// -->
</form>

---

Text Content

LOADING... PLEASE WAIT...


 
MANDATORY DOD NOTICE AND CONSENT BANNERYou are accessing a U.S. Government (USG)
Information System (IS) that is provided for USG-authorized use only. By using
this IS (which includes any device attached to this IS), you consent to the
following conditions:
 * The USG routinely intercepts and monitors communications on this IS for
   purposes including, but not limited to, penetration testing, COMSEC
   monitoring, network operations and defense, personnel misconduct (PM), law
   enforcement (LE), and counterintelligence (CI) investigations.
 * At any time, the USG may inspect and seize data stored on this IS.
 * Communications using, or data stored on, this IS are not private, are subject
   to routine monitoring, interception, and search, and may be disclosed or used
   for any USG-authorized purpose.
 * This IS includes security measures (e.g., authentication and access controls)
   to protect USG interests—not for your personal benefit or privacy.
 * Notwithstanding the above, using this IS does not constitute consent to PM,
   LE or CI investigative searching or monitoring of the content of privileged
   communications, or work product, related to personal representation or
   services by attorneys, psychotherapists, or clergy, and their assistants.
   Such communications and work product are private and confidential. See User
   Agreement for details.

Accept DoD Notice

--------------------------------------------------------------------------------

SIGN IN

--------------------------------------------------------------------------------

Please enter your email and PIN below

Incorrect email or PIN

This token recently expired

Login
Register with Token
 
 
MANDATORY DOD NOTICE AND CONSENT BANNERYou are accessing a U.S. Government (USG)
Information System (IS) that is provided for USG-authorized use only. By using
this IS (which includes any device attached to this IS), you consent to the
following conditions:
 * The USG routinely intercepts and monitors communications on this IS for
   purposes including, but not limited to, penetration testing, COMSEC
   monitoring, network operations and defense, personnel misconduct (PM), law
   enforcement (LE), and counterintelligence (CI) investigations.
 * At any time, the USG may inspect and seize data stored on this IS.
 * Communications using, or data stored on, this IS are not private, are subject
   to routine monitoring, interception, and search, and may be disclosed or used
   for any USG-authorized purpose.
 * This IS includes security measures (e.g., authentication and access controls)
   to protect USG interests—not for your personal benefit or privacy.
 * Notwithstanding the above, using this IS does not constitute consent to PM,
   LE or CI investigative searching or monitoring of the content of privileged
   communications, or work product, related to personal representation or
   services by attorneys, psychotherapists, or clergy, and their assistants.
   Such communications and work product are private and confidential. See User
   Agreement for details.

Accept DoD Notice

--------------------------------------------------------------------------------

PLEASE ENTER THE FOLLOWING INFORMATION TO REGISTER

--------------------------------------------------------------------------------

















There was an issue with your registration. Please try again or contact your
facility.
Register
Scan My CAC
 
 
Please hold your CAC sideways and point your camera at the front of it. Change
video source:


Cancel
 

--------------------------------------------------------------------------------

PLEASE UPDATE YOUR PROFILE INFORMATION

--------------------------------------------------------------------------------

Please enter your primary and secondary email addresses if they have changed






--------------------------------------------------------------------------------

Please update your primary and secondary phone numbers if they have changed





Update Profile or Continue to Surveys
 
Logout


PATIENT REPORTED OUTCOMES

Please complete the following:


 

 
Skip Back

Previous Page Next Page Submit
Save and Continue Later Cancel



Your session is about to expire!

--------------------------------------------------------------------------------

Your session will expire in 120 seconds!

Do you want to continue your session?

--------------------------------------------------------------------------------

Yes, Keep Working No, Log Out

Sign In


--------------------------------------------------------------------------------

SIGN IN

--------------------------------------------------------------------------------

Please enter your secure password (it is different from your PIN)

Incorrect password

Login

Forgot password?









Change Password


--------------------------------------------------------------------------------

CHANGE YOUR PASSWORD

--------------------------------------------------------------------------------

Please enter and confirm your new password below

Update








Set Password


--------------------------------------------------------------------------------

SET YOUR PASSWORD

--------------------------------------------------------------------------------

Please enter and confirm your password below. Please also specify a cell phone
number for two factor authentication.

Set Password