if (window.location.protocol != "https:" && window.location.href.indexOf("formulate") == -1 && "False" === "True") { window.location.href = "https:" + window.location.href.substring(window.location.protocol.length); } var fbScriptTag = document.getElementsByClassName("37ff8ca2-e52e-449f-b568-1a99a58def7d"), fbBodyTag = document.body, fbHeadTag = document.head, fbIsTestResponse = 'False', fbEnableInstaMedScript = 'False', fbRenderContainer = document.createElement("div"), fbRenderedCssContainer = document.createElement("div"), fbConfigScript = document.createElement("script"), fbRequireJSScript = document.createElement("script"), fbInstaMedJSScript = document.createElement("script"), fbGeoCaptchaCallback = document.createElement("script"), fbGeoReCaptchaCallback = document.createElement("script"), fbFormulateRenderer = document.createElement("script"), fbRenderedIntegrations = document.createElement("script"), fbRenderedScripts = document.createElement("script"), fbAutoPopulateFromQueryString = document.createElement("script"), fbEmbeddedCss = "", renderedScripts = ''; if(fbScriptTag.length === 0) { fbScriptTag = document.querySelector("script[src*='37ff8ca2-e52e-449f-b568-1a99a58def7d']"); } else { fbScriptTag = fbScriptTag[0]; } fbRenderContainer.id = "formRenderContainer"; fbRenderContainer.className = " fbRenderContainer fbRenderContainer_37ff8ca2-e52e-449f-b568-1a99a58def7d"; fbRenderedCssContainer.id = "fbRenderedCssContainer"; fbConfigScript.type = "text/javascript"; fbRequireJSScript.type = "text/javascript"; fbInstaMedJSScript.type = "text/javascript"; fbGeoCaptchaCallback.type = "text/javascript"; fbGeoReCaptchaCallback.type = "text/javascript"; fbFormulateRenderer.type = "text/javascript"; fbRenderedIntegrations.type = "text/javascript"; fbRenderedScripts.type = "text/javascript"; fbAutoPopulateFromQueryString.type = "text/javascript"; fbRequireJSScript.src = "https://formulate.geonetric.com/Scripts/require.min.js"; fbInstaMedJSScript.src = "https://formulate.geonetric.com/Scripts/vendor/instamed/token.js"; fbInstaMedJSScript.id = "instamed-sdk"; fbGeoCaptchaCallback.src = "https://formulate.geonetric.com/Scripts/geo-captcha-callback.js"; fbGeoReCaptchaCallback.src = "https://www.google.com/recaptcha/api.js?onload=geoFbCaptchaCallback&render=6LdxkTEpAAAAAMKbkhz8-INpQis_mvSaIXnoyC2V"; fbFormulateRenderer.src = "https://formulate.geonetric.com/Scripts/require/formulate-renderer.js?embeddedCssType=0&isTestResponse=False&hasGoogleAnalytics=False"; fbFormulateRenderer.id = "formulateRendererScript"; fbAutoPopulateFromQueryString.src = "https://formulate.geonetric.com/Scripts/auto-populate-from-query-string.js"; if (fbEnableInstaMedScript === 'True') { fbInstaMedJSScript.setAttribute("data-displaymode", "embedded"); fbInstaMedJSScript.setAttribute("data-environment", "UAT"); fbInstaMedJSScript.setAttribute("data-mobiledisplaymode", "embedded"); } fbGeoCaptchaCallback.onload = function() { if(document.querySelectorAll('.geo-fb-recaptcha').length > 0) { fbBodyTag.appendChild(fbGeoReCaptchaCallback); } } fbRequireJSScript.addEventListener("load", function() { fbBodyTag.appendChild(fbFormulateRenderer); fbBodyTag.appendChild(fbAutoPopulateFromQueryString); }); fbFormulateRenderer.addEventListener("load", function () { initFormBuilderForm(); }); var embeddedCssType = 0 switch (embeddedCssType) { case 1: fbEmbeddedCss = ''; break; case 2: fbEmbeddedCss = ''; break; default: fbEmbeddedCss = ''; } if (fbIsTestResponse === 'True') { fbRenderContainer.setAttribute('data-test-mode', 'true'); } else { fbRenderContainer.setAttribute('data-test-mode', 'false'); } fbRenderContainer.innerHTML = "
\

Required fields are marked with *

\ \ \ \ \ \ \ \ \ \
\ Full Legal Name\ \
\ \
\ \ \
\
\
\ \
\ \ \
\
\
\
\ \
\ \
\ \
\ \
\

HIPPA

\

Tuberculosis (TB) Test

Patient Safety Training

What does PDCA stand for?

\ \
\ \
\ \
\ \
\ \

What are the two most common Patient Identifiers?

\ \
\ \

Name the 5 different age groups:

\ \
\ \
\ \
\ \
\ \

Code Amber Alert

Environment of Care (EOC)

\ \

What is MSDS?

\ \
\ \
\ \
\ \

What does RACE stand for?

\ \
\ \
\ \
\ \

What does PASS stand for?

\ \
\ \
\ \
\ \

HIV Aids and Hepatitis

\ \

Bloodborne Pathogens

Volunteer Heart Attack and Stroke Test

Volunteer Hypoglycemia Test

Terms and Conditions

Users are advised that the information submitted through this form may be transmitted over unsecured email and releases EvergreenHealth and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the Email Form or the transmission thereof.  By selecting the "I agree to Terms and Conditions" checkbox user acknowledges these terms and conditions and consents to transmission of the form.

The following fields are required or invalid.

\ \
\
\
"; fbConfigScript.innerHTML = "window.formHost = 'https://formulate.geonetric.com'; window.submissionHost = 'https://formulate.geonetric.com/';"; fbRenderedScripts.innerHTML = renderedScripts.replace(/