{"id":2860,"date":"2018-07-17T15:51:12","date_gmt":"2018-07-17T19:51:12","guid":{"rendered":"https:\/\/www.med.unc.edu\/cspsc\/scheduling\/cspsc-scheduling-form\/"},"modified":"2023-12-19T11:31:58","modified_gmt":"2023-12-19T16:31:58","slug":"cspsc-scheduling-form","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/cspsc\/scheduling\/cspsc-scheduling-form\/","title":{"rendered":"SET Center Scheduling Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">SET Center Scheduling Form<\/h2>\n                            <p class='gform_description'>To schedule an event in the SET Center or request further information about scheduling an event, please complete the following form.  We will respond to your request shortly.  Please note that events are not added to our calendar until you have received confirmation.<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/cspsc\/wp-json\/wp\/v2\/pages\/2860\/' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_1\" 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\">Contact Information<\/h3><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-text 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_2_3'>Primary Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-phone 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_2_4'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Additional Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='tel' value='' class='small'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-email 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_2_6'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_2_6' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Group\/Department Name<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_8\" class=\"gfield gfield--type-checkbox gfield--type-choice 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' >Room Request (Please Select All That Apply.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_8'><div class='gchoice gchoice_2_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Patient Exam Rooms 24 available'  id='choice_2_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_1' id='label_2_8_1' class='gform-field-label gform-field-label--type-inline'>Patient Exam Rooms 24 available<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='Sim Lab 1- Hospital Room'  id='choice_2_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_2' id='label_2_8_2' class='gform-field-label gform-field-label--type-inline'>Sim Lab 1- Hospital Room<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='Sim Lab 2 - 3 bed Trauma Bay'  id='choice_2_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_3' id='label_2_8_3' class='gform-field-label gform-field-label--type-inline'>Sim Lab 2 - 3 bed Trauma Bay<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.4' type='checkbox'  value='Sim Lab 3 - Hospital Room'  id='choice_2_8_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_4' id='label_2_8_4' class='gform-field-label gform-field-label--type-inline'>Sim Lab 3 - Hospital Room<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.5' type='checkbox'  value='Sim Lab 4- Hospital Room'  id='choice_2_8_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_5' id='label_2_8_5' class='gform-field-label gform-field-label--type-inline'>Sim Lab 4- Hospital Room<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.6' type='checkbox'  value='Sim Lab 5- Hospital Room'  id='choice_2_8_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_6' id='label_2_8_6' class='gform-field-label gform-field-label--type-inline'>Sim Lab 5- Hospital Room<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.7' type='checkbox'  value='Sim Lab 6- Operating Room'  id='choice_2_8_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_7' id='label_2_8_7' class='gform-field-label gform-field-label--type-inline'>Sim Lab 6- Operating Room<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.8' type='checkbox'  value='Debrief Room 4206- seats 14'  id='choice_2_8_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_8' id='label_2_8_8' class='gform-field-label gform-field-label--type-inline'>Debrief Room 4206- seats 14<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.9' type='checkbox'  value='Debrief Room 4223 - seats 6'  id='choice_2_8_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_9' id='label_2_8_9' class='gform-field-label gform-field-label--type-inline'>Debrief Room 4223 - seats 6<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.11' type='checkbox'  value='Debrief Room 4225 - seats 6'  id='choice_2_8_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_11' id='label_2_8_11' class='gform-field-label gform-field-label--type-inline'>Debrief Room 4225 - seats 6<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.12' type='checkbox'  value='Skills and Procedure Room - Seats 36'  id='choice_2_8_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_12' id='label_2_8_12' class='gform-field-label gform-field-label--type-inline'>Skills and Procedure Room - Seats 36<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_8_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.13' type='checkbox'  value='Debrief Room - 5226- Seats 12'  id='choice_2_8_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_13' id='label_2_8_13' class='gform-field-label gform-field-label--type-inline'>Debrief Room - 5226- Seats 12<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_9\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Number of Exam Rooms<\/label><div class='gfield_description' id='gfield_description_2_9'>Enter up to 24<\/div><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='small'  aria-describedby=\"gfield_description_2_9\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Number Of Standardized Patients<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_10'>Select 'No' if you will not need SPs<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_10'>\n\t\t\t<div class='gchoice gchoice_2_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Yes'  id='choice_2_10_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_10\"   \/>\n\t\t\t\t\t<label for='choice_2_10_0' id='label_2_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_2_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_10_1' id='label_2_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_20\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>If yes, how many Standardized Patients will be needed<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div data-fieldId=\"20\" class=\"spacer gfield\" style=\"grid-column: span 8;\" data-groupId=\"382079fe\"><\/div><fieldset id=\"field_2_11\" class=\"gfield gfield--type-date gfield--input-type-datefield 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' >Start Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_2_11' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_11_1_container'>\n                                            <input type='number' maxlength='2' name='input_11[]' id='input_2_11_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_2_11_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_11_2_container'>\n                                            <input type='number' maxlength='2' name='input_11[]' id='input_2_11_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_2_11_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_11_3_container'>\n                                            <input type='number' maxlength='4' name='input_11[]' id='input_2_11_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_2_11_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_2_12\" class=\"gfield gfield--type-time 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' >Start Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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_2_12'>\n                            <input type='number' name='input_12[]' id='input_2_12_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_2_12_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_12[]' id='input_2_12_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_2_12_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_12[]' id='input_2_12_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_2_12_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_2_13\" class=\"gfield gfield--type-date gfield--input-type-datefield 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' >End Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_2_13' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_13_1_container'>\n                                            <input type='number' maxlength='2' name='input_13[]' id='input_2_13_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_2_13_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_13_2_container'>\n                                            <input type='number' maxlength='2' name='input_13[]' id='input_2_13_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_2_13_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_13_3_container'>\n                                            <input type='number' maxlength='4' name='input_13[]' id='input_2_13_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_2_13_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_2_14\" class=\"gfield gfield--type-time 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' >End Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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_2_14'>\n                            <input type='number' name='input_14[]' id='input_2_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_2_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_2_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_2_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_2_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_2_14_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_2_15\" 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_2_15'>Is This A Recurring Event? 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field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Additional Comments\/Requests:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_2_17' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_18\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below 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value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"143\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/www.med.unc.edu\/cspsc\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = 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);} ); \n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Task Trainer Request Form<\/h3>\n                            <p class='gform_description'>To reserve simulation equipment or request further information about equipment needs, please complete the following form.  We will respond to your request shortly.  Please note that no reservations are added to our calendar until you have received confirmation.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/cspsc\/wp-json\/wp\/v2\/pages\/2860\/' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_1\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contact Information<\/h2><\/li><li id=\"field_5_3\" class=\"gfield gfield--type-text 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_5_3'>Primary Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_5_3' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_4\" class=\"gfield gfield--type-phone 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_5_4'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_5_4' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_5\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_5'>Additional Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_5_5' type='tel' value='' class='small'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_6\" class=\"gfield gfield--type-email 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_5_6'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_5_6' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>Group\/Department Name<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_8\" class=\"gfield gfield--type-checkbox gfield--type-choice 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 gfield_label_before_complex' >Equipment Request (Please Select All That Apply.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_8'><li class='gchoice gchoice_5_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Airway Heads (Adult &amp; Peds) a.\tIntubation b.\tAirway Management c.\tCricothyroidotomy'  id='choice_5_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_1' id='label_5_8_1' class='gform-field-label gform-field-label--type-inline'>Airway Heads (Adult &amp; Peds) a.\tIntubation b.\tAirway Management c.\tCricothyroidotomy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='Ultrasound Trainers (Adult &amp; Peds) a.\tCardiac Ultrasound b.\tTEE c.\tPOCUS d.\tEFAST e.\tOB\/GYN'  id='choice_5_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_2' id='label_5_8_2' class='gform-field-label gform-field-label--type-inline'>Ultrasound Trainers (Adult &amp; Peds) a.\tCardiac Ultrasound b.\tTEE c.\tPOCUS d.\tEFAST e.\tOB\/GYN<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='Intraossious Trainer    a.IO Access'  id='choice_5_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_3' id='label_5_8_3' class='gform-field-label gform-field-label--type-inline'>Intraossious Trainer    a.IO Access<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.4' type='checkbox'  value='IV Start Arms a.IV Starts b.Blood Draws'  id='choice_5_8_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_4' id='label_5_8_4' class='gform-field-label gform-field-label--type-inline'>IV Start Arms a.IV Starts b.Blood Draws<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.5' type='checkbox'  value='Pelvic Trainers a.\tPelvic Exam b.\tPap Smear'  id='choice_5_8_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_5' id='label_5_8_5' class='gform-field-label gform-field-label--type-inline'>Pelvic Trainers a.\tPelvic Exam b.\tPap Smear<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.6' type='checkbox'  value='Suture Pads a.\tSuturing'  id='choice_5_8_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_6' id='label_5_8_6' class='gform-field-label gform-field-label--type-inline'>Suture Pads a.\tSuturing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.7' type='checkbox'  value='Foley Catheter Trainer a.\tMale Catheterization Training b.\tFemale Catheterization Training'  id='choice_5_8_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_7' id='label_5_8_7' class='gform-field-label gform-field-label--type-inline'>Foley Catheter Trainer a.\tMale Catheterization Training b.\tFemale Catheterization Training<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.8' type='checkbox'  value='Central Line Trainer a.\tCentral Line Placement b.\tUltrasound Compatible'  id='choice_5_8_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_8' id='label_5_8_8' class='gform-field-label gform-field-label--type-inline'>Central Line Trainer a.\tCentral Line Placement b.\tUltrasound Compatible<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.9' type='checkbox'  value='Lumbar Puncture Trainer (Adult &amp; Peds) a.\tUltrasound Compatible'  id='choice_5_8_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_9' id='label_5_8_9' class='gform-field-label gform-field-label--type-inline'>Lumbar Puncture Trainer (Adult &amp; Peds) a.\tUltrasound Compatible<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.11' type='checkbox'  value='Arterial Line Trainer a.\tArterial Line Placement b.\tBlood Gas Sampling'  id='choice_5_8_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_11' id='label_5_8_11' class='gform-field-label gform-field-label--type-inline'>Arterial Line Trainer a.\tArterial Line Placement b.\tBlood Gas Sampling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.12' type='checkbox'  value='Chest Tube Trainer a.\tChest Tube Placement b.\tUltrasound Compatible c.\tPneumothorax Needle Decompression'  id='choice_5_8_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_12' id='label_5_8_12' class='gform-field-label gform-field-label--type-inline'>Chest Tube Trainer a.\tChest Tube Placement b.\tUltrasound Compatible c.\tPneumothorax Needle Decompression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.13' type='checkbox'  value='Joint Injection Trainers a.\tJoint injection with feedback'  id='choice_5_8_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_13' id='label_5_8_13' class='gform-field-label gform-field-label--type-inline'>Joint Injection Trainers a.\tJoint injection with feedback<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_8_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.14' type='checkbox'  value='Rectal Trainer a. Rectal Exam  b. Prostate Exam'  id='choice_5_8_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_8_14' id='label_5_8_14' class='gform-field-label gform-field-label--type-inline'>Rectal Trainer a. Rectal Exam  b. Prostate Exam<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_10\" class=\"gfield gfield--type-radio gfield--type-choice 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' >Will You Need A Sim Tech For This Session?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_10'>Please note that sim tech availability is not guaranteed.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_10'>\n\t\t\t<li class='gchoice gchoice_5_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Yes'  id='choice_5_10_0'    \/>\n\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='No'  id='choice_5_10_1'    \/>\n\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I Understand The Confirmed Times Will Include 30 Minutes Before And After The Requested Times<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_18'>\n\t\t\t<li class='gchoice gchoice_5_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_5_18_0'    \/>\n\t\t\t\t<label for='choice_5_18_0' id='label_5_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_11\" class=\"gfield gfield--type-date gfield--input-type-datefield 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 gfield_label_before_complex' >Start Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_5_11' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_11_1_container'>\n                                            <input type='number' maxlength='2' name='input_11[]' id='input_5_11_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_5_11_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_11_2_container'>\n                                            <input type='number' maxlength='2' name='input_11[]' id='input_5_11_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_5_11_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_11_3_container'>\n                                            <input type='number' maxlength='4' name='input_11[]' id='input_5_11_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_5_11_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id=\"field_5_12\" class=\"gfield gfield--type-time 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 gfield_label_before_complex' >Start Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_5_12'>\n                            <input type='number' name='input_12[]' id='input_5_12_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_5_12_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_12[]' id='input_5_12_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_5_12_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_12[]' id='input_5_12_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_5_12_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_5_13\" class=\"gfield gfield--type-date gfield--input-type-datefield 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 gfield_label_before_complex' >End Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_5_13' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_13_1_container'>\n                                            <input type='number' maxlength='2' name='input_13[]' id='input_5_13_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_5_13_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_13_2_container'>\n                                            <input type='number' maxlength='2' name='input_13[]' id='input_5_13_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_5_13_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_13_3_container'>\n                                            <input type='number' maxlength='4' name='input_13[]' id='input_5_13_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_5_13_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/div><\/li><li id=\"field_5_14\" class=\"gfield gfield--type-time 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 gfield_label_before_complex' >End Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_5_14'>\n                            <input type='number' name='input_14[]' id='input_5_14_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_5_14_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_14[]' id='input_5_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_5_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_5_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_5_14_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_5_15\" 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_5_15'>Is This A Recurring Event? If So, Please List Additional Dates:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_5_15' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_16\" class=\"gfield gfield--type-textarea 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_5_16'>Please Give A Brief Description And Location Of Your Event (Include All Pertinent Equipment And\/Or Adapters You Will Use):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_5_16' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'>Location:\n\nBrief Description:\n\nAdditional 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