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Submitted URL: https://redcap.link/iotm3fyp
Effective URL: https://redcap.dellmed.utexas.edu/surveys/?s=J4LEF9JCTL8M339C
Submission: On February 23 via manual from US — Scanned from DE
Effective URL: https://redcap.dellmed.utexas.edu/surveys/?s=J4LEF9JCTL8M339C
Submission: On February 23 via manual from US — Scanned from DE
Form analysis
1 forms found in the DOMName: form — POST /surveys/index.php?s=J4LEF9JCTL8M339C
<form action="/surveys/index.php?s=J4LEF9JCTL8M339C" enctype="multipart/form-data" target="_self" method="post" name="form" id="form"><input type="hidden" name="redcap_csrf_token" value="">
<div>
<script type="text/javascript">
if (typeof lang == 'undefined') {
var lang = {}
};
lang.global_143 = 'Checked';
lang.global_144 = 'Unchecked';
</script>
<script type="text/javascript">
var missing_data_replacement_js = '______';
var piping_receiver_class_field_js = '.piping_receiver.piperec-';
</script>
<span id="maxchecked_tag_label" class="" style="display:none;z-index:1000;" data-rc-lang="data_entry_421">Cannot select choice! The maximum number of choices has been selected.</span><span id="matrix_rank_remove_label" class="opacity75"
style="display:none;" data-rc-lang="data_entry_203">Value removed!</span>
<div id="questiontable_loading" style="visibility: visible; display: none;">
<img alt="Loading..." src="/redcap_v12.5.9/Resources/images/progress_circle.gif"> <span data-rc-lang="data_entry_64">Loading...</span>
</div>
<script type="text/javascript">
setTimeout(function() {
document.getElementById('questiontable_loading').style.visibility = 'visible';
}, 750);
</script>
<table role="presentation" class="form_border container-fluid" style="display: table;" id="questiontable">
<tbody class="formtbody">
<tr id="sex-tr" sq_id="sex" req="1">
<td class="labelrc questionnum col-1" valign="top">1)</td>
<td class="labelrc col-6"><label class="fl" id="label-sex">
<div data-kind="field-label">
<div data-mlm-field="sex" data-mlm-type="label"> Sex</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="sex" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-sex">
<div class="choicevert"><input type="radio" id="opt-sex_1" tabindex="0" name="sex___radio" aria-labelledby="label-sex label-sex-1" onclick="document.forms['form'].sex.value=this.value;" value="1"> <label data-mlm-field="sex"
data-mlm-type="enum" data-mlm-value="1" id="label-sex-1" for="opt-sex_1" class="mc">Female</label></div>
<div class="choicevert"><input type="radio" id="opt-sex_2" tabindex="0" name="sex___radio" aria-labelledby="label-sex label-sex-2" onclick="document.forms['form'].sex.value=this.value;" value="2"> <label data-mlm-field="sex"
data-mlm-type="enum" data-mlm-value="2" id="label-sex-2" for="opt-sex_2" class="mc">Male</label></div>
<div class="choicevert"><input type="radio" id="opt-sex_3" tabindex="0" name="sex___radio" aria-labelledby="label-sex label-sex-3" onclick="document.forms['form'].sex.value=this.value;" value="3"> <label data-mlm-field="sex"
data-mlm-type="enum" data-mlm-value="3" id="label-sex-3" for="opt-sex_3" class="mc">Non-binary</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('sex','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="sex_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="age-tr" sq_id="age" req="1">
<td class="labelrc questionnum col-1" valign="top">2)</td>
<td class="labelrc col-6"><label class="fl" id="label-age">
<div data-kind="field-label">
<div data-mlm-field="age" data-mlm-type="label"> Age</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-required="true" aria-labelledby="label-age" class="x-form-text x-form-field " type="text" name="age" value="" tabindex="0"></span>
<div id="age_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="race-tr" sq_id="race" req="1">
<td class="labelrc questionnum col-1" valign="top">3)</td>
<td class="labelrc col-6"><label class="fl" id="label-race">
<div data-kind="field-label">
<div data-mlm-field="race" data-mlm-type="label"> Race</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="race" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-race">
<div class="choicevert"><input type="radio" id="opt-race_1" tabindex="0" name="race___radio" aria-labelledby="label-race label-race-1" onclick="document.forms['form'].race.value=this.value;" value="1"> <label data-mlm-field="race"
data-mlm-type="enum" data-mlm-value="1" id="label-race-1" for="opt-race_1" class="mc">White</label></div>
<div class="choicevert"><input type="radio" id="opt-race_2" tabindex="0" name="race___radio" aria-labelledby="label-race label-race-2" onclick="document.forms['form'].race.value=this.value;" value="2"> <label data-mlm-field="race"
data-mlm-type="enum" data-mlm-value="2" id="label-race-2" for="opt-race_2" class="mc">African-American</label></div>
<div class="choicevert"><input type="radio" id="opt-race_3" tabindex="0" name="race___radio" aria-labelledby="label-race label-race-3" onclick="document.forms['form'].race.value=this.value;" value="3"> <label data-mlm-field="race"
data-mlm-type="enum" data-mlm-value="3" id="label-race-3" for="opt-race_3" class="mc">Latino-Hispanic</label></div>
<div class="choicevert"><input type="radio" id="opt-race_4" tabindex="0" name="race___radio" aria-labelledby="label-race label-race-4" onclick="document.forms['form'].race.value=this.value;" value="4"> <label data-mlm-field="race"
data-mlm-type="enum" data-mlm-value="4" id="label-race-4" for="opt-race_4" class="mc">Asian</label></div>
<div class="choicevert"><input type="radio" id="opt-race_5" tabindex="0" name="race___radio" aria-labelledby="label-race label-race-5" onclick="document.forms['form'].race.value=this.value;" value="5"> <label data-mlm-field="race"
data-mlm-type="enum" data-mlm-value="5" id="label-race-5" for="opt-race_5" class="mc">Native Hawaiian or other Pacific Islander</label></div>
<div class="choicevert"><input type="radio" id="opt-race_6" tabindex="0" name="race___radio" aria-labelledby="label-race label-race-6" onclick="document.forms['form'].race.value=this.value;" value="6"> <label data-mlm-field="race"
data-mlm-type="enum" data-mlm-value="6" id="label-race-6" for="opt-race_6" class="mc">Other</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('race','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="race_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="marital_status-tr" sq_id="marital_status" req="1">
<td class="labelrc questionnum col-1" valign="top">4)</td>
<td class="labelrc col-6"><label class="fl" id="label-marital_status">
<div data-kind="field-label">
<div data-mlm-field="marital_status" data-mlm-type="label"> Marital Status</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="marital_status" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-marital_status">
<div class="choicevert"><input type="radio" id="opt-marital_status_1" tabindex="0" name="marital_status___radio" aria-labelledby="label-marital_status label-marital_status-1"
onclick="document.forms['form'].marital_status.value=this.value;" value="1"> <label data-mlm-field="marital_status" data-mlm-type="enum" data-mlm-value="1" id="label-marital_status-1" for="opt-marital_status_1" class="mc">Married or
partner</label></div>
<div class="choicevert"><input type="radio" id="opt-marital_status_2" tabindex="0" name="marital_status___radio" aria-labelledby="label-marital_status label-marital_status-2"
onclick="document.forms['form'].marital_status.value=this.value;" value="2"> <label data-mlm-field="marital_status" data-mlm-type="enum" data-mlm-value="2" id="label-marital_status-2" for="opt-marital_status_2" class="mc">Divorced
or seperated</label></div>
<div class="choicevert"><input type="radio" id="opt-marital_status_3" tabindex="0" name="marital_status___radio" aria-labelledby="label-marital_status label-marital_status-3"
onclick="document.forms['form'].marital_status.value=this.value;" value="3"> <label data-mlm-field="marital_status" data-mlm-type="enum" data-mlm-value="3" id="label-marital_status-3" for="opt-marital_status_3"
class="mc">Single</label></div>
<div class="choicevert"><input type="radio" id="opt-marital_status_4" tabindex="0" name="marital_status___radio" aria-labelledby="label-marital_status label-marital_status-4"
onclick="document.forms['form'].marital_status.value=this.value;" value="4"> <label data-mlm-field="marital_status" data-mlm-type="enum" data-mlm-value="4" id="label-marital_status-4" for="opt-marital_status_4"
class="mc">Widowed</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('marital_status','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="marital_status_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="education-tr" sq_id="education" req="1">
<td class="labelrc questionnum col-1" valign="top">5)</td>
<td class="labelrc col-6"><label class="fl" id="label-education">
<div data-kind="field-label">
<div data-mlm-field="education" data-mlm-type="label"> Highest level of education</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="education" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-education">
<div class="choicevert"><input type="radio" id="opt-education_1" tabindex="0" name="education___radio" aria-labelledby="label-education label-education-1" onclick="document.forms['form'].education.value=this.value;" value="1"> <label
data-mlm-field="education" data-mlm-type="enum" data-mlm-value="1" id="label-education-1" for="opt-education_1" class="mc">Highschool or less</label></div>
<div class="choicevert"><input type="radio" id="opt-education_2" tabindex="0" name="education___radio" aria-labelledby="label-education label-education-2" onclick="document.forms['form'].education.value=this.value;" value="2"> <label
data-mlm-field="education" data-mlm-type="enum" data-mlm-value="2" id="label-education-2" for="opt-education_2" class="mc">Some college</label></div>
<div class="choicevert"><input type="radio" id="opt-education_3" tabindex="0" name="education___radio" aria-labelledby="label-education label-education-3" onclick="document.forms['form'].education.value=this.value;" value="3"> <label
data-mlm-field="education" data-mlm-type="enum" data-mlm-value="3" id="label-education-3" for="opt-education_3" class="mc">College graduate</label></div>
<div class="choicevert"><input type="radio" id="opt-education_4" tabindex="0" name="education___radio" aria-labelledby="label-education label-education-4" onclick="document.forms['form'].education.value=this.value;" value="4"> <label
data-mlm-field="education" data-mlm-type="enum" data-mlm-value="4" id="label-education-4" for="opt-education_4" class="mc">Master's degree</label></div>
<div class="choicevert"><input type="radio" id="opt-education_5" tabindex="0" name="education___radio" aria-labelledby="label-education label-education-5" onclick="document.forms['form'].education.value=this.value;" value="5"> <label
data-mlm-field="education" data-mlm-type="enum" data-mlm-value="5" id="label-education-5" for="opt-education_5" class="mc">Post-college graduate degree (e.g. PhD)</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('education','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="education_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="insurance-tr" sq_id="insurance" req="1">
<td class="labelrc questionnum col-1" valign="top">6)</td>
<td class="labelrc col-6"><label class="fl" id="label-insurance">
<div data-kind="field-label">
<div data-mlm-field="insurance" data-mlm-type="label"> Insurance type</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="insurance" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-insurance">
<div class="choicevert"><input type="radio" id="opt-insurance_1" tabindex="0" name="insurance___radio" aria-labelledby="label-insurance label-insurance-1" onclick="document.forms['form'].insurance.value=this.value;" value="1"> <label
data-mlm-field="insurance" data-mlm-type="enum" data-mlm-value="1" id="label-insurance-1" for="opt-insurance_1" class="mc">Medicare</label></div>
<div class="choicevert"><input type="radio" id="opt-insurance_2" tabindex="0" name="insurance___radio" aria-labelledby="label-insurance label-insurance-2" onclick="document.forms['form'].insurance.value=this.value;" value="2"> <label
data-mlm-field="insurance" data-mlm-type="enum" data-mlm-value="2" id="label-insurance-2" for="opt-insurance_2" class="mc">Medicaid</label></div>
<div class="choicevert"><input type="radio" id="opt-insurance_3" tabindex="0" name="insurance___radio" aria-labelledby="label-insurance label-insurance-3" onclick="document.forms['form'].insurance.value=this.value;" value="3"> <label
data-mlm-field="insurance" data-mlm-type="enum" data-mlm-value="3" id="label-insurance-3" for="opt-insurance_3" class="mc">MAP</label></div>
<div class="choicevert"><input type="radio" id="opt-insurance_4" tabindex="0" name="insurance___radio" aria-labelledby="label-insurance label-insurance-4" onclick="document.forms['form'].insurance.value=this.value;" value="4"> <label
data-mlm-field="insurance" data-mlm-type="enum" data-mlm-value="4" id="label-insurance-4" for="opt-insurance_4" class="mc">Private</label></div>
<div class="choicevert"><input type="radio" id="opt-insurance_5" tabindex="0" name="insurance___radio" aria-labelledby="label-insurance label-insurance-5" onclick="document.forms['form'].insurance.value=this.value;" value="5"> <label
data-mlm-field="insurance" data-mlm-type="enum" data-mlm-value="5" id="label-insurance-5" for="opt-insurance_5" class="mc">Uninsured</label></div>
<div class="choicevert"><input type="radio" id="opt-insurance_6" tabindex="0" name="insurance___radio" aria-labelledby="label-insurance label-insurance-6" onclick="document.forms['form'].insurance.value=this.value;" value="6"> <label
data-mlm-field="insurance" data-mlm-type="enum" data-mlm-value="6" id="label-insurance-6" for="opt-insurance_6" class="mc">Other</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('insurance','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="insurance_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="employment-tr" sq_id="employment" req="1">
<td class="labelrc questionnum col-1" valign="top">7)</td>
<td class="labelrc col-6"><label class="fl" id="label-employment">
<div data-kind="field-label">
<div data-mlm-field="employment" data-mlm-type="label"> Employment status</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="employment" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-employment">
<div class="choicevert"><input type="radio" id="opt-employment_1" tabindex="0" name="employment___radio" aria-labelledby="label-employment label-employment-1" onclick="document.forms['form'].employment.value=this.value;" value="1">
<label data-mlm-field="employment" data-mlm-type="enum" data-mlm-value="1" id="label-employment-1" for="opt-employment_1" class="mc">Unemployed</label></div>
<div class="choicevert"><input type="radio" id="opt-employment_2" tabindex="0" name="employment___radio" aria-labelledby="label-employment label-employment-2" onclick="document.forms['form'].employment.value=this.value;" value="2">
<label data-mlm-field="employment" data-mlm-type="enum" data-mlm-value="2" id="label-employment-2" for="opt-employment_2" class="mc">Employed part time</label></div>
<div class="choicevert"><input type="radio" id="opt-employment_3" tabindex="0" name="employment___radio" aria-labelledby="label-employment label-employment-3" onclick="document.forms['form'].employment.value=this.value;" value="3">
<label data-mlm-field="employment" data-mlm-type="enum" data-mlm-value="3" id="label-employment-3" for="opt-employment_3" class="mc">Employed full time</label></div>
<div class="choicevert"><input type="radio" id="opt-employment_4" tabindex="0" name="employment___radio" aria-labelledby="label-employment label-employment-4" onclick="document.forms['form'].employment.value=this.value;" value="4">
<label data-mlm-field="employment" data-mlm-type="enum" data-mlm-value="4" id="label-employment-4" for="opt-employment_4" class="mc">Retired</label></div>
<div class="choicevert"><input type="radio" id="opt-employment_5" tabindex="0" name="employment___radio" aria-labelledby="label-employment label-employment-5" onclick="document.forms['form'].employment.value=this.value;" value="5">
<label data-mlm-field="employment" data-mlm-type="enum" data-mlm-value="5" id="label-employment-5" for="opt-employment_5" class="mc">Unable to work</label></div>
<div class="choicevert"><input type="radio" id="opt-employment_6" tabindex="0" name="employment___radio" aria-labelledby="label-employment label-employment-6" onclick="document.forms['form'].employment.value=this.value;" value="6">
<label data-mlm-field="employment" data-mlm-type="enum" data-mlm-value="6" id="label-employment-6" for="opt-employment_6" class="mc">Other</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('employment','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="employment_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="income-tr" sq_id="income" req="1">
<td class="labelrc questionnum col-1" valign="top">8)</td>
<td class="labelrc col-6"><label class="fl" id="label-income">
<div data-kind="field-label">
<div data-mlm-field="income" data-mlm-type="label"> Income</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="income" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-income">
<div class="choicevert"><input type="radio" id="opt-income_1" tabindex="0" name="income___radio" aria-labelledby="label-income label-income-1" onclick="document.forms['form'].income.value=this.value;" value="1"> <label
data-mlm-field="income" data-mlm-type="enum" data-mlm-value="1" id="label-income-1" for="opt-income_1" class="mc"><24.000</label></div>
<div class="choicevert"><input type="radio" id="opt-income_2" tabindex="0" name="income___radio" aria-labelledby="label-income label-income-2" onclick="document.forms['form'].income.value=this.value;" value="2"> <label
data-mlm-field="income" data-mlm-type="enum" data-mlm-value="2" id="label-income-2" for="opt-income_2" class="mc">$24.000 - $46.000</label></div>
<div class="choicevert"><input type="radio" id="opt-income_3" tabindex="0" name="income___radio" aria-labelledby="label-income label-income-3" onclick="document.forms['form'].income.value=this.value;" value="3"> <label
data-mlm-field="income" data-mlm-type="enum" data-mlm-value="3" id="label-income-3" for="opt-income_3" class="mc">$46.000 - $75.000</label></div>
<div class="choicevert"><input type="radio" id="opt-income_4" tabindex="0" name="income___radio" aria-labelledby="label-income label-income-4" onclick="document.forms['form'].income.value=this.value;" value="4"> <label
data-mlm-field="income" data-mlm-type="enum" data-mlm-value="4" id="label-income-4" for="opt-income_4" class="mc">$75.000 - $121.000</label></div>
<div class="choicevert"><input type="radio" id="opt-income_5" tabindex="0" name="income___radio" aria-labelledby="label-income label-income-5" onclick="document.forms['form'].income.value=this.value;" value="5"> <label
data-mlm-field="income" data-mlm-type="enum" data-mlm-value="5" id="label-income-5" for="opt-income_5" class="mc">> $121.000</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('income','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="income_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="location-tr" sq_id="location" req="1">
<td class="labelrc questionnum col-1" valign="top">9)</td>
<td class="labelrc col-6"><label class="fl" id="label-location">
<div data-kind="field-label">
<div data-mlm-field="location" data-mlm-type="label"> Where is your injury located?</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="location" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-location">
<div class="choicevert"><input type="radio" id="opt-location_1" tabindex="0" name="location___radio" aria-labelledby="label-location label-location-1" onclick="document.forms['form'].location.value=this.value;" value="1"> <label
data-mlm-field="location" data-mlm-type="enum" data-mlm-value="1" id="label-location-1" for="opt-location_1" class="mc">Arm</label></div>
<div class="choicevert"><input type="radio" id="opt-location_2" tabindex="0" name="location___radio" aria-labelledby="label-location label-location-2" onclick="document.forms['form'].location.value=this.value;" value="2"> <label
data-mlm-field="location" data-mlm-type="enum" data-mlm-value="2" id="label-location-2" for="opt-location_2" class="mc">Leg</label></div>
<div class="choicevert"><input type="radio" id="opt-location_3" tabindex="0" name="location___radio" aria-labelledby="label-location label-location-3" onclick="document.forms['form'].location.value=this.value;" value="3"> <label
data-mlm-field="location" data-mlm-type="enum" data-mlm-value="3" id="label-location-3" for="opt-location_3" class="mc">Spine</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('location','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="location_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="trauma_vs_non_trauma-tr" sq_id="trauma_vs_non_trauma" req="1">
<td class="labelrc questionnum col-1" valign="top">10)</td>
<td class="labelrc col-6"><label class="fl" id="label-trauma_vs_non_trauma">
<div data-kind="field-label">
<div data-mlm-field="trauma_vs_non_trauma" data-mlm-type="label"> Was your injury the result of a trauma?</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input name="trauma_vs_non_trauma" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-trauma_vs_non_trauma">
<div class="choicevert"><input type="radio" id="opt-trauma_vs_non_trauma_1" tabindex="0" name="trauma_vs_non_trauma___radio" aria-labelledby="label-trauma_vs_non_trauma label-trauma_vs_non_trauma-1"
onclick="document.forms['form'].trauma_vs_non_trauma.value=this.value;" value="1"> <label data-mlm-field="trauma_vs_non_trauma" data-mlm-type="enum" data-mlm-value="1" id="label-trauma_vs_non_trauma-1"
for="opt-trauma_vs_non_trauma_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-trauma_vs_non_trauma_2" tabindex="0" name="trauma_vs_non_trauma___radio" aria-labelledby="label-trauma_vs_non_trauma label-trauma_vs_non_trauma-2"
onclick="document.forms['form'].trauma_vs_non_trauma.value=this.value;" value="2"> <label data-mlm-field="trauma_vs_non_trauma" data-mlm-type="enum" data-mlm-value="2" id="label-trauma_vs_non_trauma-2"
for="opt-trauma_vs_non_trauma_2" class="mc">No</label></div>
</span>
<div data-kind="reset-link" class="resetLinkParent d-print-none">
<a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('trauma_vs_non_trauma','form');return false;"><span data-rc-lang="form_renderer_20">reset</span></a></div>
<div id="trauma_vs_non_trauma_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<input type="hidden" name="submit-action" id="submit-action" value="<span data-rc-lang="data_entry_206">Save Record</span>">
<input type="hidden" name="__start_time__" id="__start_time__" value="2023-02-23 11:37:37">
<input type="hidden" name="record_id" id="record_id" value="1">
<input type="hidden" name="__page__" value="1">
<input type="hidden" name="__page_hash__" value="ec17b70338adf5536377ff7c60fdc240">
<input type="hidden" name="__response_hash__" value="">
<input type="hidden" name="demographics_complete" value="">
<tr class="surveysubmit">
<td class="labelrc col-12" style="padding:5px;" colspan="3">
<table cellspacing="0">
<tbody>
<tr>
<td colspan="2" style="text-align:center;padding:15px 0;">
<button name="submit-btn-saverecord" tabindex="0" class="jqbutton nowrap ui-button ui-corner-all ui-widget" style="color:#800000;min-width:140px;"
onclick="$(this).button("disable");dataEntrySubmit(this);return false;"><span data-rc-lang="survey_200">Submit</span></button>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</div><input type="hidden" name="external-modules-temporary-record-id" value="external-modules-temporary-record-id-1677173857-773132258">
</form>
Text Content
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. 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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4})) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/ /^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/ /^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/ /^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/ /^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/ 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/^[-+]?\b\d+\b$/ /^[a-z]+$/i /^\d{10}$/ /^[a-z0-9-_]+$/i /^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/ /^-?\d+,\d$/ /^-?\d+\.\d$/ /^-?\d+,\d{2}$/ /^-?\d+\.\d{2}$/ /^-?\d+,\d{3}$/ /^-?\d+\.\d{3}$/ /^-?\d+,\d{4}$/ /^-?\d+\.\d{4}$/ /^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/ /^(\(0[2-8]\)|0[2-8])\s*\d{4}\s*\d{4}$/ /^(?:\(?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)\)?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/ /^((((\+44|0044)\s?\d{4}|\(?0\d{4}\)?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|\(?0\d{3}\)?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|\(?0\d{2}\)?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/ /^\d{4}$/ /^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i /^(0[1-9]|[1-9]\d)\d{3}$/ /^\d{3}-\d\d-\d{4}$/ /^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/ /^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/ /^[0-5]\d:[0-5]\d$/ /^\d{2}-\d{4}-(\d{2}|\d{4})$/ /^[0-9]{4,9}$/ /^\d{5}(-\d{4})?$/ YHhGM7Q36USg6e7xBBeToJypDr7Pm4BPjfdkohe4m3GA9UMEXpqfMbTrRbQaN6sArSJePSRJQQTkQACpEwWDttWEjWHcgyIy A A A Please complete the survey below. Thank you! Cannot select choice! The maximum number of choices has been selected.Value removed! Loading... 1) Sex * must provide value Female Male Non-binary reset 2) Age * must provide value 3) Race * must provide value White African-American Latino-Hispanic Asian Native Hawaiian or other Pacific Islander Other reset 4) Marital Status * must provide value Married or partner Divorced or seperated Single Widowed reset 5) Highest level of education * must provide value Highschool or less Some college College graduate Master's degree Post-college graduate degree (e.g. PhD) reset 6) Insurance type * must provide value Medicare Medicaid MAP Private Uninsured Other reset 7) Employment status * must provide value Unemployed Employed part time Employed full time Retired Unable to work Other reset 8) Income * must provide value <24.000 $24.000 - $46.000 $46.000 - $75.000 $75.000 - $121.000 > $121.000 reset 9) Where is your injury located? * must provide value Arm Leg Spine reset 10) Was your injury the result of a trauma? * must provide value Yes No reset Submit YOU HAVE SELECTED AN OPTION THAT TRIGGERS THIS SURVEY TO END RIGHT NOW. To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button. Powered by REDCap