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URL:
https://my.primary.health/a/mn-retirement-testing?access_code=57867444B549B2BE
Submission: On April 20 via manual from US — Scanned from DE
Submission: On April 20 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
POST https://my.primary.health/test_groups/mn-retirement-testing/validate_credentials
<form data-parsley-validate="true" novalidate="" class="simple_form user" action="https://my.primary.health/test_groups/mn-retirement-testing/validate_credentials" accept-charset="UTF-8" method="post"><input type="hidden" name="authenticity_token"
value="rj7gn/BAAplbB59p16uGLDH/Y9/n2830CGMUS0MdKQKW3OIHzarqceQFWc75LYGSbr3y5+ZD1KvAhGqqUcEhFA==">
<input type="hidden" value="" name="locale">
<input type="hidden" value="" name="year" id="birth_year">
<input type="hidden" value="" name="key">
<input type="hidden" value="" name="registration_type">
<input type="hidden" value="" name="consent_bypass">
<input type="hidden" value="" name="population">
<input type="hidden" value="" name="jump_to_consent">
<div class="row pt-2" id="access_code_form">
<div class="col-lg">
<div class="mb-3 string required user_access_code input-container select-container"><label class="form-label string required filled" for="user_access_code">Access Code <abbr class="text-danger">*</abbr></label><input
class="form-control string required" name="access_code" value="57867444B549B2BE" aria-label="access code, required" aria-describedby="date-of-birth-errors" required="required" aria-required="true" type="text" id="user_access_code"
data-parsley-errors-container="#access-code-errors"></div>
<div id="access-code-errors"></div>
</div>
</div>
<div class="row">
<div class="col-lg">
<div class="mb-3 string required user_last_name input-container select-container"><label class="form-label string required" for="user_last_name">Last name <abbr class="text-danger">*</abbr></label><input class="form-control string required"
name="last_name" aria-label="last name, required" aria-describedby="date-of-birth-errors" required="required" aria-required="true" type="text" id="user_last_name" data-parsley-errors-container="#last-name-errors"></div>
<div id="last-name-errors"></div>
</div>
</div>
<div class="row">
<div class="col-lg-6">
<div>
<!-- Accessibility issue: PRH-38 Unlabelled controls -->
<div style="height:0px;overflow: hidden;">
<label class="form-label date required" for="user_date_of_birth_datetime_3i">Day of birth</label>
<label class="form-label date required" for="user_date_of_birth_datetime_1i">Year of birth</label>
</div>
<div class="mb-3 date required user_date_of_birth_datetime"><label class="form-label date required" for="user_date_of_birth_datetime_2i">Date of birth <abbr class="text-danger">*</abbr></label>
<div class="d-flex flex-row justify-content-between align-items-center"><select id="user_date_of_birth_datetime_2i" name="user[date_of_birth_datetime(2i)]" class="form-select form-select-lg mx-1 date required"
aria-label="date of birth month, required" aria-describedby="date-of-birth-errors" required="required" aria-required="true" data-parsley-is-valid-date="" data-parsley-required-fields="" data-parsley-required-message=""
data-parsley-errors-messages-disabled="true">
<option value=""></option>
<option value="1">January</option>
<option value="2">February</option>
<option value="3">March</option>
<option value="4">April</option>
<option value="5">May</option>
<option value="6">June</option>
<option value="7">July</option>
<option value="8">August</option>
<option value="9">September</option>
<option value="10">October</option>
<option value="11">November</option>
<option value="12">December</option>
</select>
<select id="user_date_of_birth_datetime_3i" name="user[date_of_birth_datetime(3i)]" class="form-select form-select-lg mx-1 date required" aria-label="date of birth day, required" aria-describedby="date-of-birth-errors" required="required"
aria-required="true" data-parsley-is-valid-date="" data-parsley-required-fields="" data-parsley-required-message="" data-parsley-errors-messages-disabled="true">
<option value=""></option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select id="user_date_of_birth_datetime_1i" name="user[date_of_birth_datetime(1i)]" class="form-select form-select-lg mx-1 date required" aria-label="date of birth year, required" aria-describedby="date-of-birth-errors"
required="required" aria-required="true" data-parsley-is-valid-date="" data-parsley-required-fields="" data-parsley-year-length="" data-parsley-errors-container="#date-of-birth-errors">
<option value=""></option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
</select>
</div>
</div>
</div>
</div>
</div>
<div id="date-of-birth-errors"></div>
<div class="my-4">
<input type="submit" name="commit" value="Submit" class="btn pure-button" data-disable-with="Submit">
</div>
</form>POST https://api.kustomerapp.com/v1/hooks/form/5ffe150d32c4a19ca48305ef/b38925aae4e653a827f28925810590e96bff7d36880457999ca5b7f1194e92a3
<form method="post" data-parsley-validate="true" action="https://api.kustomerapp.com/v1/hooks/form/5ffe150d32c4a19ca48305ef/b38925aae4e653a827f28925810590e96bff7d36880457999ca5b7f1194e92a3" id="kustomer_form" novalidate="">
<input type="hidden" name="location_url" value="https://my.primary.health/a/mn-retirement-testing?access_code=57867444B549B2BE">
<input type="hidden" name="test_group" value="mn-retirement-testing">
<input type="hidden" name="org" value="MN Retirement Employer Testing">
<input type="hidden" name="org_support_phone" value="">
<input type="hidden" name="org_email" value="">
<input type="hidden" name="patient_organization" value="MN-MSRS-0122">
<input type="hidden" name="user_access_code" value="57867444B549B2BE">
<input type="hidden" name="_wpcf7_locale" value="">
<input type="hidden" name="zen_subject" value="Website User Support">
<div class="form-row">
<div class="col-md-6">
<label for="kustomer_contact_name" class="form-label">Contact Name *</label>
<input type="text" name="zen_name" required="required" aria-required="true" class="form-control" id="kustomer_contact_name" placeholder="John Doe">
</div>
<div class="col-md-6">
<label for="kustomer_email" class="form-label">Email *</label>
<input type="email" name="zen_email" required="required" aria-required="true" class="form-control" id="kustomer_email" placeholder="Email">
</div>
</div>
<div>
<label for="kustomer_phone_number" class="form-label">Mobile Phone Number</label>
<input type="tel" name="phone_number" autocomplete="tel-national" class="form-control" id="kustomer_phone_number" placeholder="Mobile Phone Number">
</div>
<div>
<label for="kustomer_ticket_type" class="form-label">What is this regarding? *</label>
<select id="kustomer_ticket_type" required="required" aria-required="true" name="ticket_type" class="form-control" data-parsley-is-selected="">
<option></option>
<option value="test">Test</option>
<option value="vaccine">Vaccine</option>
<option value="other">Other</option>
</select>
</div>
<div>
<label for="kustomer_confirmation_code" class="form-label">Confirmation Code (if known)</label>
<input type="tel" name="appointment_access_code" autocomplete="tel-national" class="form-control" id="kustomer_confirmation_code">
</div>
<div class="form-row">
<div class="col-md-6">
<label for="inputCity" class="form-label">City</label>
<input type="text" name="city" class="form-control" id="inputCity">
</div>
<div class="col-md-6">
<label for="inputState" class="form-label">State</label>
<select id="inputState" name="state" class="form-control">
<option></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
</div>
<div>
<label for="kustomer_message" class="form-label">Message *</label>
<textarea class="form-control" required="required" aria-required="true" name="zen_desc" id="kustomer_message" rows="3"></textarea>
</div>
<button type="submit" class="btn btn-primary" id="kustomer_submit">Submit</button>
</form>Text Content
Get Help Assistive TechnologyEnglish EnglishEspañol WELCOME TO THE MN STATE RETIREMENT SYSTEM'S COVID-19 EMPLOYEE TESTING PROGRAM. The implementation of this program is in compliance with HIPAA and OSHA standards for safety in the workplace. Please add your last name and birth date to begin the registration process. Your birthday will be used to allow test results input later during testing. Thank you for your participation! Access Code * Last name * Day of birth Year of birth Date of birth * January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 CONTACT US SUCCESS! Your request has been received. We sent you an email with your confirmation. Contact Name * Email * Mobile Phone Number What is this regarding? * Test Vaccine Other Confirmation Code (if known) City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia 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 West Virginia Wisconsin Wyoming Message * Submit Close Powered by Primary.Health Built by Primary.Health