{"id":379,"date":"2023-02-10T14:11:33","date_gmt":"2023-02-10T14:11:33","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=379"},"modified":"2023-02-10T14:11:33","modified_gmt":"2023-02-10T14:11:33","slug":"trauma-survivors-network","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/trauma-survivors-network\/","title":{"rendered":"Trauma Survivors Network"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_105' style='display:none'><div id='gf_105' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_105' id='gform_105'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/379#gf_105' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_105' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_105_1\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>The Trauma Survivors Network at UAB aims to build a community and provide resources to support trauma survivors and their families.<\/p>\n\n<p>We are excited you are joining the network! If you have any questions, please email us at <a href=\"mailto:traumasurvivors@uabmc.edu\">traumasurvivors@uabmc.edu<\/a>. <\/p><\/div><fieldset id=\"field_105_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_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 no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_105_2'>\n                            \n                            <span id='input_105_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_105_2_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_105_2_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_105_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_105_2_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_105_2_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_105_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_105_3' >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_3' id='input_105_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_105_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_105_4' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_105_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_105_5\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Please indicate which phone number you listed.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_5'>\n\t\t\t<div class='gchoice gchoice_105_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Home'  id='choice_105_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_5_0' id='label_105_5_0'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Work'  id='choice_105_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_5_1' id='label_105_5_1'>Work<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Cell'  id='choice_105_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_5_2' id='label_105_5_2'>Cell<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_105_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_105_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_105_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_105_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_105_6_1' id='input_105_6_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_105_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_105_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_105_6_2' id='input_105_6_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_105_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_105_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_105_6_3' id='input_105_6_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_105_6_4_container' >\n                                        <select name='input_6.4' id='input_105_6_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_105_6_4' id='input_105_6_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_105_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_105_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_105_6_5' id='input_105_6_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_105_6_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_105_8\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Would you like to be registered as part of the national Trauma Survivors Network?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_8'>\n\t\t\t<div class='gchoice gchoice_105_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_105_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_8_0' id='label_105_8_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_105_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_8_1' id='label_105_8_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_105_10\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >How do you identify?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_10'>\n\t\t\t<div class='gchoice gchoice_105_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Trauma survivor'  id='choice_105_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_10_0' id='label_105_10_0'>Trauma survivor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Friend, family member, or caregiver of a trauma survivor'  id='choice_105_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_10_1' id='label_105_10_1'>Friend, family member, or caregiver of a trauma survivor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Health care provider'  id='choice_105_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_10_2' id='label_105_10_2'>Health care provider<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_10_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='gf_other_choice'  id='choice_105_10_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_10_3' id='label_105_10_3'>Other<\/label><br \/><input id='input_105_10_other' name='input_10_other' type='text' value='Other' aria-label='Other Choice, please specify'   disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_105_11\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_105_11' >Injury Date (if applicable)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_11' id='input_105_11' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_105_11_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_105_11_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_105_11' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_105_19\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are you current patient who wants to be seen by a trauma survivor peer visitor?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_19'>\n\t\t\t<div class='gchoice gchoice_105_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_105_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_19_0' id='label_105_19_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_105_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_19_1' id='label_105_19_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_105_20\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_105_20' >Please provide your room number<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_105_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_105_12\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Injury information (select all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_105_12'><div class='gchoice gchoice_105_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Motor vehicle accident'  id='choice_105_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_1' id='label_105_12_1'>Motor vehicle accident<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Motorcycle accident'  id='choice_105_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_2' id='label_105_12_2'>Motorcycle accident<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='ATV accident'  id='choice_105_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_3' id='label_105_12_3'>ATV accident<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Fall'  id='choice_105_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_4' id='label_105_12_4'>Fall<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='Burn'  id='choice_105_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_5' id='label_105_12_5'>Burn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='Firearm'  id='choice_105_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_6' id='label_105_12_6'>Firearm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.7' type='checkbox'  value='Cut or pierce'  id='choice_105_12_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_7' id='label_105_12_7'>Cut or pierce<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.8' type='checkbox'  value='Assault'  id='choice_105_12_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_8' id='label_105_12_8'>Assault<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.9' type='checkbox'  value='Self-harm'  id='choice_105_12_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_9' id='label_105_12_9'>Self-harm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.11' type='checkbox'  value='Natural disaster'  id='choice_105_12_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_11' id='label_105_12_11'>Natural disaster<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.12' type='checkbox'  value='Machinery'  id='choice_105_12_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_12' id='label_105_12_12'>Machinery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.13' type='checkbox'  value='Traumatic brain injury'  id='choice_105_12_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_13' id='label_105_12_13'>Traumatic brain injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.14' type='checkbox'  value='Spinal cord injury'  id='choice_105_12_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_14' id='label_105_12_14'>Spinal cord injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.15' type='checkbox'  value='Amputation'  id='choice_105_12_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_15' id='label_105_12_15'>Amputation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.16' type='checkbox'  value='Loss of mobility'  id='choice_105_12_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_16' id='label_105_12_16'>Loss of mobility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.17' type='checkbox'  value='Other'  id='choice_105_12_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_17' id='label_105_12_17'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.18' type='checkbox'  value='I\u2019d prefer not to answer'  id='choice_105_12_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_18' id='label_105_12_18'>I\u2019d prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_12_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.19' type='checkbox'  value='N\/A'  id='choice_105_12_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_12_19' id='label_105_12_19'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_105_16\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_105_16' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_105_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_105_13\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >What are you interested in learning more about? (Select all that apply):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_105_13'><div class='gchoice gchoice_105_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Local, state, or national resources'  id='choice_105_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_1' id='label_105_13_1'>Local, state, or national resources<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Mental health support'  id='choice_105_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_2' id='label_105_13_2'>Mental health support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='An online class to help me during my road to recovery (NextSteps)'  id='choice_105_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_3' id='label_105_13_3'>An online class to help me during my road to recovery (NextSteps)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Support groups for survivors'  id='choice_105_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_4' id='label_105_13_4'>Support groups for survivors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Support groups for friends, family members, and caregivers'  id='choice_105_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_5' id='label_105_13_5'>Support groups for friends, family members, and caregivers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Sharing my or my loved one\u2019s story'  id='choice_105_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_6' id='label_105_13_6'>Sharing my or my loved one\u2019s story<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Volunteering with current trauma patients (peer visitation)'  id='choice_105_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_7' id='label_105_13_7'>Volunteering with current trauma patients (peer visitation)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_105_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Volunteering with friends, family members, and caregivers'  id='choice_105_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_105_13_8' id='label_105_13_8'>Volunteering with friends, family members, and caregivers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice 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