redcap.dellmed.utexas.edu Open in urlscan Pro
128.83.124.7  Public Scan

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

Form analysis 1 forms found in the DOM

Name: formPOST /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">&lt;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">&gt; $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=&quot;data_entry_206&quot;>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(&quot;disable&quot;);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.
Required format:
/^[uU][tT][sS][0][a-zA-Z0-9]{8}$/
/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/
/^((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}))$/
/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/
/^(((\d{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))))$/
/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))
(\d|[0-1]\d|[2][0-3]):[0-5]\d$/
/^((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}$/
/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u00FF\u0100-\u017F\u0180-\u024F\u0250-\u02AF\u0300-\u036F\u0370-\u03FF\u0400-\u04FF\u0500-\u052F\u0530-\u058F\u0590-\u05FF\u0600-\u06FF\u0700-\u074F\u0750-\u077F\u0780-\u07BF\u07C0-\u07FF\u0900-\u097F\u0980-\u09FF\u0A00-\u0A7F\u0A80-\u0AFF\u0B00-\u0B7F\u0B80-\u0BFF\u0C00-\u0C7F\u0C80-\u0CFF\u0D00-\u0D7F\u0D80-\u0DFF\u0E00-\u0E7F\u0E80-\u0EFF\u0F00-\u0FFF\u1000-\u109F\u10A0-\u10FF\u1100-\u11FF\u1200-\u137F\u1380-\u139F\u13A0-\u13FF\u1400-\u167F\u1680-\u169F\u16A0-\u16FF\u1700-\u171F\u1720-\u173F\u1740-\u175F\u1760-\u177F\u1780-\u17FF\u1800-\u18AF\u1900-\u194F\u1950-\u197F\u1980-\u19DF\u19E0-\u19FF\u1A00-\u1A1F\u1B00-\u1B7F\u1D00-\u1D7F\u1D80-\u1DBF\u1DC0-\u1DFF\u1E00-\u1EFF\u1F00-\u1FFF\u20D0-\u20FF\u2100-\u214F\u2C00-\u2C5F\u2C60-\u2C7F\u2C80-\u2CFF\u2D00-\u2D2F\u2D30-\u2D7F\u2D80-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u309F\u30A0-\u30FF\u3100-\u312F\u3130-\u318F\u3190-\u319F\u31C0-\u31EF\u31F0-\u31FF\u3200-\u32FF\u3300-\u33FF\u3400-\u4DBF\u4DC0-\u4DFF\u4E00-\u9FFF\uA000-\uA48F\uA490-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\.!#$%&'*+-/=?^_`{|}~\-\d]+)@(?!\.)([a-zA-Z0-9\u0080-\u00FF\u0100-\u017F\u0180-\u024F\u0250-\u02AF\u0300-\u036F\u0370-\u03FF\u0400-\u04FF\u0500-\u052F\u0530-\u058F\u0590-\u05FF\u0600-\u06FF\u0700-\u074F\u0750-\u077F\u0780-\u07BF\u07C0-\u07FF\u0900-\u097F\u0980-\u09FF\u0A00-\u0A7F\u0A80-\u0AFF\u0B00-\u0B7F\u0B80-\u0BFF\u0C00-\u0C7F\u0C80-\u0CFF\u0D00-\u0D7F\u0D80-\u0DFF\u0E00-\u0E7F\u0E80-\u0EFF\u0F00-\u0FFF\u1000-\u109F\u10A0-\u10FF\u1100-\u11FF\u1200-\u137F\u1380-\u139F\u13A0-\u13FF\u1400-\u167F\u1680-\u169F\u16A0-\u16FF\u1700-\u171F\u1720-\u173F\u1740-\u175F\u1760-\u177F\u1780-\u17FF\u1800-\u18AF\u1900-\u194F\u1950-\u197F\u1980-\u19DF\u19E0-\u19FF\u1A00-\u1A1F\u1B00-\u1B7F\u1D00-\u1D7F\u1D80-\u1DBF\u1DC0-\u1DFF\u1E00-\u1EFF\u1F00-\u1FFF\u20D0-\u20FF\u2100-\u214F\u2C00-\u2C5F\u2C60-\u2C7F\u2C80-\u2CFF\u2D00-\u2D2F\u2D30-\u2D7F\u2D80-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u309F\u30A0-\u30FF\u3100-\u312F\u3130-\u318F\u3190-\u319F\u31C0-\u31EF\u31F0-\u31FF\u3200-\u32FF\u3300-\u33FF\u3400-\u4DBF\u4DC0-\u4DFF\u4E00-\u9FFF\uA000-\uA48F\uA490-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u00FF\u0100-\u017F\u0180-\u024F\u0250-\u02AF\u0300-\u036F\u0370-\u03FF\u0400-\u04FF\u0500-\u052F\u0530-\u058F\u0590-\u05FF\u0600-\u06FF\u0700-\u074F\u0750-\u077F\u0780-\u07BF\u07C0-\u07FF\u0900-\u097F\u0980-\u09FF\u0A00-\u0A7F\u0A80-\u0AFF\u0B00-\u0B7F\u0B80-\u0BFF\u0C00-\u0C7F\u0C80-\u0CFF\u0D00-\u0D7F\u0D80-\u0DFF\u0E00-\u0E7F\u0E80-\u0EFF\u0F00-\u0FFF\u1000-\u109F\u10A0-\u10FF\u1100-\u11FF\u1200-\u137F\u1380-\u139F\u13A0-\u13FF\u1400-\u167F\u1680-\u169F\u16A0-\u16FF\u1700-\u171F\u1720-\u173F\u1740-\u175F\u1760-\u177F\u1780-\u17FF\u1800-\u18AF\u1900-\u194F\u1950-\u197F\u1980-\u19DF\u19E0-\u19FF\u1A00-\u1A1F\u1B00-\u1B7F\u1D00-\u1D7F\u1D80-\u1DBF\u1DC0-\u1DFF\u1E00-\u1EFF\u1F00-\u1FFF\u20D0-\u20FF\u2100-\u214F\u2C00-\u2C5F\u2C60-\u2C7F\u2C80-\u2CFF\u2D00-\u2D2F\u2D30-\u2D7F\u2D80-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u309F\u30A0-\u30FF\u3100-\u312F\u3130-\u318F\u3190-\u319F\u31C0-\u31EF\u31F0-\u31FF\u3200-\u32FF\u3300-\u33FF\u3400-\u4DBF\u4DC0-\u4DFF\u4E00-\u9FFF\uA000-\uA48F\uA490-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i
/^[-+]?\b\d+\b$/
/^[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