{"id":1170,"date":"2021-12-09T18:47:19","date_gmt":"2021-12-09T18:47:19","guid":{"rendered":"https:\/\/www.nicholls.edu\/health\/?page_id=1170"},"modified":"2021-12-09T20:56:19","modified_gmt":"2021-12-09T20:56:19","slug":"incident-report-2","status":"publish","type":"page","link":"https:\/\/www.nicholls.edu\/health\/incident-report-2\/","title":{"rendered":"Incident Report"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1170\" class=\"elementor elementor-1170\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-415609e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"415609e\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1a095f2\" data-id=\"1a095f2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d860835 elementor-widget elementor-widget-shortcode\" data-id=\"d860835\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_6' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/health\/wp-json\/wp\/v2\/pages\/1170' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_6_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you completing this form for yourself or someone else?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_28'>\n\t\t\t<div class='gchoice gchoice_6_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Myself'  id='choice_6_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_0' id='label_6_28_0' class='gform-field-label gform-field-label--type-inline'>Myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Someone else \/ employee \/ student'  id='choice_6_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_1' id='label_6_28_1' class='gform-field-label gform-field-label--type-inline'>Someone else \/ employee \/ student<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_29\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of Employee\/Student\/Other<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_29'>\n                            \n                            <span id='input_6_29_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_29.3' id='input_6_29_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_29_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_29_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_29.6' id='input_6_29_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_29_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_30\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_30'>ID number (N number) of Employee\/Student\/Other<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_6_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_9\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your Information<\/h3><\/div><fieldset id=\"field_6_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_2\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_2'>ÐÓ°É´«Ã½ Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_6_2' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_3\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_3'>N number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_6_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_4\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_4'>Job Title<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_6_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_5\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Department<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_6_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_6\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_6'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_6_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_7\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_7'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_6_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_11'>\n\t\t\t<div class='gchoice gchoice_6_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Male'  id='choice_6_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_11_0' id='label_6_11_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Female'  id='choice_6_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_11_1' id='label_6_11_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_12\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_6_12' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_12_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_12_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_12' class='gform_hidden' value='https:\/\/www.nicholls.edu\/health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_8\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_6_8_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_8_1' id='input_6_8_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_6_8_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_8_2' id='input_6_8_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_6_8_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_8_3' id='input_6_8_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_8_4_container' >\n                                        <input type='text' name='input_8.4' id='input_6_8_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_8_4' id='input_6_8_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_6_8_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_8_5' id='input_6_8_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_6_8_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Incident Information<\/h3><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Date of Incident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_6_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_13_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_13' class='gform_hidden' value='https:\/\/www.nicholls.edu\/health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_14\" class=\"gfield gfield--type-time gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Time of Incident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_6_14'>\n                            <input type='number' name='input_14[]' id='input_6_14_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_6_14_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_14[]' id='input_6_14_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_6_14_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_14[]' id='input_6_14_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_6_14_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_6_15\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_15'>Date Reported<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_6_15' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_15' class='gform_hidden' value='https:\/\/www.nicholls.edu\/health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_16\" class=\"gfield gfield--type-time gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Time Reported<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_6_16'>\n                            <input type='number' name='input_16[]' id='input_6_16_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_6_16_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_16[]' id='input_6_16_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_6_16_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_16[]' id='input_6_16_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_6_16_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_6_22\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_22'>Location of accident\/incident<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_6_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_17'>Describe accident\/incident<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_6_17' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_24\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_24'>Describe injury\/illness:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_6_24' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Witnesses<\/h3><\/div><fieldset id=\"field_6_21\" class=\"gfield gfield--type-list field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List witnesses below<\/legend><div class='gfield_description' id='gfield_description_6_21'>Click \"+\" to add more witnesses.<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Phone<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Address<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_21_cell1 gform-grid-col' data-label='Name'><input aria-invalid='false'  aria-describedby=\"gfield_description_6_21\" aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_21[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_21_cell2 gform-grid-col' data-label='Phone'><input aria-invalid='false'  aria-describedby=\"gfield_description_6_21\" aria-label='Phone, Row 1' data-aria-label-template='Phone, Row {0}' type='text' name='input_21[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_21_cell3 gform-grid-col' data-label='Address'><input aria-invalid='false'  aria-describedby=\"gfield_description_6_21\" aria-label='Address, Row 1' data-aria-label-template='Address, Row {0}' type='text' name='input_21[]' value=''   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placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_25_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_25_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_25' class='gform_hidden' value='https:\/\/www.nicholls.edu\/health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_26\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Person Reporting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_26'>\n                            \n                            <span id='input_6_26_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.3' id='input_6_26_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_26_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_26_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.6' id='input_6_26_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_26_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_27\" class=\"gfield gfield--type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_27'>Person Reporting Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_6_27'>Please sign below with your finger (mobile) or mouse (computer).<\/div><input type='hidden' value='' name='input_27' id='input_6_27_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_27_Container' class='gfield_signature_container 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