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  <div id=\"cid_116\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_116\" name=\"q116_nameOneField\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_116\" required=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_email\" id=\"id_4\"><label class=\"form-label form-label-top\" id=\"label_4\" for=\"input_4\"> Email<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_4\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"email\" id=\"input_4\" name=\"q4_email\" class=\"form-textbox validate[required, Email]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"email\" aria-labelledby=\"label_4 sublabel_input_4\" required=\"\" \/><label class=\"form-sub-label\" for=\"input_4\" id=\"sublabel_input_4\" style=\"min-height:13px\" aria-hidden=\"false\">example@example.com<\/label><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_phone\" id=\"id_57\"><label class=\"form-label form-label-top\" id=\"label_57\" for=\"input_57_full\"> Phone Number <\/label>\n        <div id=\"cid_57\" class=\"form-input-wide\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" id=\"input_57_full\" name=\"q57_phoneNumber[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[Fill Mask]\" data-defaultvalue=\"\" autoComplete=\"section-input_57 tel-national\" style=\"width:310px\" data-masked=\"true\" value=\"\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_57\" \/><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_83\" data-compound-hint=\",,,,Please Select,,Please Select,\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_83\" for=\"input_83_city\"> Where do you live? <\/label>\n        <div id=\"cid_83\" class=\"form-input-wide\" data-layout=\"full\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\" style=\"display:none\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_83_addr_line1\" name=\"q83_whereDo[addr_line1]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_83 address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_83 sublabel_83_addr_line1\" \/><label class=\"form-sub-label\" for=\"input_83_addr_line1\" id=\"sublabel_83_addr_line1\" style=\"min-height:13px\" aria-hidden=\"false\">Street Address<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\" style=\"display:none\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_83_addr_line2\" name=\"q83_whereDo[addr_line2]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_83 off\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_83 sublabel_83_addr_line2\" \/><label class=\"form-sub-label\" for=\"input_83_addr_line2\" id=\"sublabel_83_addr_line2\" style=\"min-height:13px\" aria-hidden=\"false\">Street Address Line 2<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-city-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_83_city\" name=\"q83_whereDo[city]\" class=\"form-textbox form-address-city\" data-defaultvalue=\"\" autoComplete=\"section-input_83 address-level2\" value=\"\" data-component=\"city\" aria-labelledby=\"label_83 sublabel_83_city\" required=\"\" \/><label class=\"form-sub-label\" for=\"input_83_city\" id=\"sublabel_83_city\" style=\"min-height:13px\" aria-hidden=\"false\">City<\/label><\/span><\/span><span class=\"form-address-line form-address-state-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><select class=\"form-dropdown form-address-state\" name=\"q83_whereDo[state]\" id=\"input_83_state\" data-component=\"state\" required=\"\" aria-labelledby=\"label_83 sublabel_83_state\" autoComplete=\"section-input_83 address-level1\">\n                    <option selected=\"\" value=\"\">Please Select<\/option>\n                    <option value=\"Alabama\">Alabama<\/option>\n                    <option value=\"Alaska\">Alaska<\/option>\n                    <option value=\"Arizona\">Arizona<\/option>\n                    <option value=\"Arkansas\">Arkansas<\/option>\n                    <option value=\"California\">California<\/option>\n                    <option value=\"Colorado\">Colorado<\/option>\n                    <option value=\"Connecticut\">Connecticut<\/option>\n                    <option value=\"Delaware\">Delaware<\/option>\n                    <option value=\"District of Columbia\">District of Columbia<\/option>\n                    <option value=\"Florida\">Florida<\/option>\n                    <option value=\"Georgia\">Georgia<\/option>\n                    <option value=\"Hawaii\">Hawaii<\/option>\n                    <option value=\"Idaho\">Idaho<\/option>\n                    <option value=\"Illinois\">Illinois<\/option>\n                    <option value=\"Indiana\">Indiana<\/option>\n                    <option value=\"Iowa\">Iowa<\/option>\n                    <option value=\"Kansas\">Kansas<\/option>\n                    <option value=\"Kentucky\">Kentucky<\/option>\n                    <option value=\"Louisiana\">Louisiana<\/option>\n                    <option value=\"Maine\">Maine<\/option>\n                    <option value=\"Maryland\">Maryland<\/option>\n                    <option value=\"Massachusetts\">Massachusetts<\/option>\n                    <option value=\"Michigan\">Michigan<\/option>\n                    <option value=\"Minnesota\">Minnesota<\/option>\n                    <option value=\"Mississippi\">Mississippi<\/option>\n                    <option value=\"Missouri\">Missouri<\/option>\n                    <option value=\"Montana\">Montana<\/option>\n                    <option value=\"Nebraska\">Nebraska<\/option>\n                    <option value=\"Nevada\">Nevada<\/option>\n                    <option value=\"New Hampshire\">New Hampshire<\/option>\n                    <option value=\"New Jersey\">New Jersey<\/option>\n                    <option value=\"New Mexico\">New Mexico<\/option>\n                    <option value=\"New York\">New York<\/option>\n                    <option value=\"North Carolina\">North Carolina<\/option>\n                    <option value=\"North Dakota\">North Dakota<\/option>\n                    <option value=\"Ohio\">Ohio<\/option>\n                    <option value=\"Oklahoma\">Oklahoma<\/option>\n                    <option value=\"Oregon\">Oregon<\/option>\n                    <option value=\"Pennsylvania\">Pennsylvania<\/option>\n                    <option value=\"Puerto Rico\">Puerto Rico<\/option>\n                    <option value=\"Rhode Island\">Rhode Island<\/option>\n                    <option value=\"South Carolina\">South Carolina<\/option>\n                    <option value=\"South Dakota\">South Dakota<\/option>\n                    <option value=\"Tennessee\">Tennessee<\/option>\n                    <option value=\"Texas\">Texas<\/option>\n                    <option value=\"Utah\">Utah<\/option>\n                    <option value=\"Vermont\">Vermont<\/option>\n                    <option value=\"Virgin Islands\">Virgin Islands<\/option>\n                    <option value=\"Virginia\">Virginia<\/option>\n                    <option value=\"Washington\">Washington<\/option>\n                    <option value=\"West Virginia\">West Virginia<\/option>\n                    <option value=\"Wisconsin\">Wisconsin<\/option>\n                    <option value=\"Wyoming\">Wyoming<\/option>\n                  <\/select><label class=\"form-sub-label\" for=\"input_83_state\" id=\"sublabel_83_state\" style=\"min-height:13px\" aria-hidden=\"false\">State<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\" style=\"display:none\"><span class=\"form-address-line form-address-zip-line jsTest-address-lineField form-address-hiddenLine\" style=\"display:none\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_83_postal\" name=\"q83_whereDo[postal]\" class=\"form-textbox form-address-postal\" data-defaultvalue=\"\" autoComplete=\"section-input_83 postal-code\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_83 sublabel_83_postal\" \/><label class=\"form-sub-label\" for=\"input_83_postal\" id=\"sublabel_83_postal\" style=\"min-height:13px\" aria-hidden=\"false\">Zip Code<\/label><\/span><\/span><\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_135\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_135\" for=\"input_135\"> I\u2019m filling out this form because: <\/label>\n        <div id=\"cid_135\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_135\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_135\" class=\"form-radio\" id=\"input_135_0\" name=\"q135_imFilling\" value=\"There\u2019s a specific experience or tip I\u2019d like to share with ProPublica.\" \/><label id=\"label_input_135_0\" for=\"input_135_0\">There\u2019s a specific experience or tip I\u2019d like to share with ProPublica.<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_135\" class=\"form-radio\" id=\"input_135_1\" name=\"q135_imFilling\" value=\"I don\u2019t have a tip, but I\u2019m willing to volunteer my expertise to this reporting effort as questions arise.\" \/><label id=\"label_input_135_1\" for=\"input_135_1\">I don\u2019t have a tip, but I\u2019m willing to volunteer my expertise to this reporting effort as questions arise.<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_136\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_136\" for=\"input_136\"> Which of the following apply to you? <\/label>\n        <div id=\"cid_136\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_136\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_136\" class=\"form-checkbox\" id=\"input_136_0\" name=\"q136_whichOf136[]\" value=\"I have, or someone I know has, peripheral artery disease.\" \/><label id=\"label_input_136_0\" for=\"input_136_0\">I have, or someone I know has, peripheral artery disease.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_136\" class=\"form-checkbox\" id=\"input_136_1\" name=\"q136_whichOf136[]\" value=\"I am a health care provider working with patients who have peripheral artery disease.\" \/><label id=\"label_input_136_1\" for=\"input_136_1\">I am a health care provider working with patients who have peripheral artery disease.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_136\" class=\"form-checkbox\" id=\"input_136_2\" name=\"q136_whichOf136[]\" value=\"I work, or have worked, for a medical device company involved in producing treatments for people with peripheral artery disease.\" \/><label id=\"label_input_136_2\" for=\"input_136_2\">I work, or have worked, for a medical device company involved in producing treatments for people with peripheral artery disease.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_136\" class=\"form-checkbox\" id=\"input_136_3\" name=\"q136_whichOf136[]\" value=\"I work, or have worked, for a regulatory agency.\" \/><label id=\"label_input_136_3\" for=\"input_136_3\">I work, or have worked, for a regulatory agency.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_136\" class=\"form-checkbox\" id=\"input_136_4\" name=\"q136_whichOf136[]\" value=\"Other\" \/><label id=\"label_input_136_4\" for=\"input_136_4\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_checkbox\" id=\"id_137\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_137\" for=\"input_137\"> Have you, or someone you know, undergone any of the following treatments for peripheral artery disease? Select all that apply. <\/label>\n        <div id=\"cid_137\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_137\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_137\" class=\"form-checkbox\" id=\"input_137_0\" name=\"q137_haveYou[]\" value=\"Atherectomy\" \/><label id=\"label_input_137_0\" for=\"input_137_0\">Atherectomy<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_137\" class=\"form-checkbox\" id=\"input_137_1\" name=\"q137_haveYou[]\" value=\"Lifestyle modifications\" \/><label id=\"label_input_137_1\" for=\"input_137_1\">Lifestyle modifications<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_137\" class=\"form-checkbox\" id=\"input_137_2\" name=\"q137_haveYou[]\" value=\"Percutaneous transluminal angioplasty (PTA), also known as balloons\" \/><label id=\"label_input_137_2\" for=\"input_137_2\">Percutaneous transluminal angioplasty (PTA), also known as balloons<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_137\" class=\"form-checkbox\" id=\"input_137_3\" name=\"q137_haveYou[]\" value=\"Stent\" \/><label id=\"label_input_137_3\" for=\"input_137_3\">Stent<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_137\" class=\"form-checkbox\" id=\"input_137_4\" name=\"q137_haveYou[]\" value=\"I don\u2019t know\" \/><label id=\"label_input_137_4\" for=\"input_137_4\">I don\u2019t know<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_137\" class=\"form-checkbox\" id=\"input_137_5\" name=\"q137_haveYou[]\" value=\"Other\" \/><label id=\"label_input_137_5\" for=\"input_137_5\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_138\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_138\" for=\"input_138\"> Please describe which treatments you have undergone: <\/label>\n        <div id=\"cid_138\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_138\" name=\"q138_pleaseDescribe\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_138\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_radio\" id=\"id_139\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_139\" for=\"input_139\"> How would you describe how the procedure went? <\/label>\n        <div id=\"cid_139\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_139\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_139\" class=\"form-radio\" id=\"input_139_0\" name=\"q139_howWould\" value=\"It went well, and I have no lingering problems.\" \/><label id=\"label_input_139_0\" for=\"input_139_0\">It went well, and I have no lingering problems.<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_139\" class=\"form-radio\" id=\"input_139_1\" name=\"q139_howWould\" value=\"It went well, but I have lingering problems.\" \/><label id=\"label_input_139_1\" for=\"input_139_1\">It went well, but I have lingering problems.<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_139\" class=\"form-radio\" id=\"input_139_2\" name=\"q139_howWould\" value=\"It went badly.\" \/><label id=\"label_input_139_2\" for=\"input_139_2\">It went badly.<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_140\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_140\" for=\"input_140\"> Why would you describe it this way? What happened? <\/label>\n        <div id=\"cid_140\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_140\" class=\"form-textarea\" name=\"q140_whyWould\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_140\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_141\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_141\" for=\"input_141\"> Which doctors were involved and when was the procedure? <\/label>\n        <div id=\"cid_141\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_141\" class=\"form-textarea\" name=\"q141_whichDoctors\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_141\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_radio\" id=\"id_142\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_142\" for=\"input_142\"> Have you, or the person you know, had any amputations? <\/label>\n        <div id=\"cid_142\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_142\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_142\" class=\"form-radio\" id=\"input_142_0\" name=\"q142_haveYou142\" value=\"Yes\" \/><label id=\"label_input_142_0\" for=\"input_142_0\">Yes<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_142\" class=\"form-radio\" id=\"input_142_1\" name=\"q142_haveYou142\" value=\"No\" \/><label id=\"label_input_142_1\" for=\"input_142_1\">No<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_143\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_143\" for=\"input_143\"> Please describe the reasons for the amputation(s) in as much detail as you are comfortable sharing, including if it took place after a procedure and its impact. <\/label>\n        <div id=\"cid_143\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_143\" class=\"form-textarea\" name=\"q143_pleaseDescribe143\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_143\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_checkbox\" id=\"id_127\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_127\" for=\"input_127\"> Which of these facilities have you had experiences with? Select all that apply. <\/label>\n        <div id=\"cid_127\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_127\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_0\" name=\"q127_whichOf116[]\" value=\"Dialysis facility\" \/><label id=\"label_input_127_0\" for=\"input_127_0\">Dialysis facility<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_1\" name=\"q127_whichOf116[]\" value=\"Hospice care facility\" \/><label id=\"label_input_127_1\" for=\"input_127_1\">Hospice care facility<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_2\" name=\"q127_whichOf116[]\" value=\"Hospital\" \/><label id=\"label_input_127_2\" for=\"input_127_2\">Hospital<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_3\" name=\"q127_whichOf116[]\" value=\"Mental health or addiction treatment center\" \/><label id=\"label_input_127_3\" for=\"input_127_3\">Mental health or addiction treatment center<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_4\" name=\"q127_whichOf116[]\" value=\"Nursing home or other long-term care facility\" \/><label id=\"label_input_127_4\" for=\"input_127_4\">Nursing home or other long-term care facility<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_5\" name=\"q127_whichOf116[]\" value=\"Outpatient clinic\/office\" \/><label id=\"label_input_127_5\" for=\"input_127_5\">Outpatient clinic\/office<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_6\" name=\"q127_whichOf116[]\" value=\"Veterans Affairs\" \/><label id=\"label_input_127_6\" for=\"input_127_6\">Veterans Affairs<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_127\" class=\"form-checkbox\" id=\"input_127_7\" name=\"q127_whichOf116[]\" value=\"Other\" \/><label id=\"label_input_127_7\" for=\"input_127_7\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_128\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_128\" for=\"input_128\"> Please describe the facility or facilities: <\/label>\n        <div id=\"cid_128\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_128\" name=\"q128_pleaseDescribe117\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_128\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_129\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_129\" for=\"input_129\"> What is the name of the facility\/ies? <\/label>\n        <div id=\"cid_129\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_129\" name=\"q129_whatIs118\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_129\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_130\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_130\" for=\"input_130\"> Where is the facility located? (City, State) <\/label>\n        <div id=\"cid_130\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_130\" name=\"q130_whereIs119\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_130\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_checkbox\" id=\"id_131\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_131\" for=\"input_131\"> What kind of health insurance did this experience involve, if any? <\/label>\n        <div id=\"cid_131\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_131\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_131\" class=\"form-checkbox\" id=\"input_131_0\" name=\"q131_whatKind120[]\" value=\"No health insurance\" \/><label id=\"label_input_131_0\" for=\"input_131_0\">No health insurance<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_131\" class=\"form-checkbox\" id=\"input_131_1\" name=\"q131_whatKind120[]\" value=\"Private insurance through my employer\" \/><label id=\"label_input_131_1\" for=\"input_131_1\">Private insurance through my employer<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_131\" class=\"form-checkbox\" id=\"input_131_2\" name=\"q131_whatKind120[]\" value=\"Medicaid\" \/><label id=\"label_input_131_2\" for=\"input_131_2\">Medicaid<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_131\" class=\"form-checkbox\" id=\"input_131_3\" name=\"q131_whatKind120[]\" value=\"Medicare\" \/><label id=\"label_input_131_3\" for=\"input_131_3\">Medicare<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_131\" class=\"form-checkbox\" id=\"input_131_4\" name=\"q131_whatKind120[]\" value=\"Tricare or other military-related insurance\" \/><label id=\"label_input_131_4\" for=\"input_131_4\">Tricare or other military-related insurance<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_131\" class=\"form-checkbox\" id=\"input_131_5\" name=\"q131_whatKind120[]\" value=\"Other\" \/><label id=\"label_input_131_5\" for=\"input_131_5\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_checkbox\" id=\"id_118\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_118\" for=\"input_118\"> Which of the following apply to you? <\/label>\n        <div id=\"cid_118\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_118\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_118\" class=\"form-checkbox\" id=\"input_118_0\" name=\"q118_whichOf[]\" value=\"I\u2019m a doctor.\" \/><label id=\"label_input_118_0\" for=\"input_118_0\">I\u2019m a doctor.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_118\" class=\"form-checkbox\" id=\"input_118_1\" name=\"q118_whichOf[]\" value=\"I\u2019m a nurse.\" \/><label id=\"label_input_118_1\" for=\"input_118_1\">I\u2019m a nurse.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_118\" class=\"form-checkbox\" id=\"input_118_2\" name=\"q118_whichOf[]\" value=\"I\u2019m a nursing assistant.\" \/><label id=\"label_input_118_2\" for=\"input_118_2\">I\u2019m a nursing assistant.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_118\" class=\"form-checkbox\" id=\"input_118_3\" name=\"q118_whichOf[]\" value=\"I\u2019m a pharmacist.\" \/><label id=\"label_input_118_3\" for=\"input_118_3\">I\u2019m a pharmacist.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_118\" class=\"form-checkbox\" id=\"input_118_4\" name=\"q118_whichOf[]\" value=\"I\u2019m a physician assistant.\" \/><label id=\"label_input_118_4\" for=\"input_118_4\">I\u2019m a physician assistant.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_118\" class=\"form-checkbox\" id=\"input_118_5\" name=\"q118_whichOf[]\" value=\"Other\" \/><label id=\"label_input_118_5\" for=\"input_118_5\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_119\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_119\" for=\"input_119\"> Please describe your work: <\/label>\n        <div id=\"cid_119\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_119\" name=\"q119_pleaseDescribe100\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_119\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_checkbox\" id=\"id_120\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_120\" for=\"input_120\"> What kind of facility do you, or have you, worked at? Select all that apply. <\/label>\n        <div id=\"cid_120\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_120\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_0\" name=\"q120_whatKind[]\" value=\"Outpatient clinic\/office\" \/><label id=\"label_input_120_0\" for=\"input_120_0\">Outpatient clinic\/office<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_1\" name=\"q120_whatKind[]\" value=\"Private practice\" \/><label id=\"label_input_120_1\" for=\"input_120_1\">Private practice<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_2\" name=\"q120_whatKind[]\" value=\"Hospital\" \/><label id=\"label_input_120_2\" for=\"input_120_2\">Hospital<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_3\" name=\"q120_whatKind[]\" value=\"Nursing home or other long-term care facility\" \/><label id=\"label_input_120_3\" for=\"input_120_3\">Nursing home or other long-term care facility<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_4\" name=\"q120_whatKind[]\" value=\"Veterans Affairs\" \/><label id=\"label_input_120_4\" for=\"input_120_4\">Veterans Affairs<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_5\" name=\"q120_whatKind[]\" value=\"Mental health and addiction treatment centers\" \/><label id=\"label_input_120_5\" for=\"input_120_5\">Mental health and addiction treatment centers<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_6\" name=\"q120_whatKind[]\" value=\"Hospice care facility\" \/><label id=\"label_input_120_6\" for=\"input_120_6\">Hospice care facility<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_7\" name=\"q120_whatKind[]\" value=\"Dialysis facility\" \/><label id=\"label_input_120_7\" for=\"input_120_7\">Dialysis facility<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_120\" class=\"form-checkbox\" id=\"input_120_8\" name=\"q120_whatKind[]\" value=\"Other\" \/><label id=\"label_input_120_8\" for=\"input_120_8\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_121\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_121\" for=\"input_121\"> Please describe the facility or facilities: <\/label>\n        <div id=\"cid_121\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_121\" name=\"q121_pleaseDescribe101\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_121\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_122\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_122\" for=\"input_122\"> What is the name of the facility or facilities where you work\/worked? <\/label>\n        <div id=\"cid_122\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_122\" name=\"q122_whatIs122\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_122\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_123\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_123\" for=\"input_123\"> Where is the facility located? (City, State) <\/label>\n        <div id=\"cid_123\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_123\" name=\"q123_whereIs\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_123\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_checkbox\" id=\"id_144\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_144\" for=\"input_144\"> Are you a current or former federal or state employee? <\/label>\n        <div id=\"cid_144\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_144\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_144\" class=\"form-checkbox\" id=\"input_144_0\" name=\"q144_areYou[]\" value=\"Current state employee\" \/><label id=\"label_input_144_0\" for=\"input_144_0\">Current state employee<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_144\" class=\"form-checkbox\" id=\"input_144_1\" name=\"q144_areYou[]\" value=\"Former state employee\" \/><label id=\"label_input_144_1\" for=\"input_144_1\">Former state employee<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_144\" class=\"form-checkbox\" id=\"input_144_2\" name=\"q144_areYou[]\" value=\"Current federal employee\" \/><label id=\"label_input_144_2\" for=\"input_144_2\">Current federal employee<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_144\" class=\"form-checkbox\" id=\"input_144_3\" name=\"q144_areYou[]\" value=\"Former federal employee\" \/><label id=\"label_input_144_3\" for=\"input_144_3\">Former federal employee<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_144\" class=\"form-checkbox\" id=\"input_144_4\" name=\"q144_areYou[]\" value=\"Other\" \/><label id=\"label_input_144_4\" for=\"input_144_4\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_145\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_145\" for=\"input_145\"> What is or was your role? <\/label>\n        <div id=\"cid_145\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_145\" name=\"q145_whatIs145\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_145\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_146\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_146\" for=\"input_146\"> What agency do you or did you work for? <\/label>\n        <div id=\"cid_146\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_146\" name=\"q146_whatAgency\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_146\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_radio\" id=\"id_147\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_147\" for=\"input_147\"> Have you encountered health care providers who may be overusing procedures to treat PAD? <\/label>\n        <div id=\"cid_147\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_147\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_147\" class=\"form-radio\" id=\"input_147_0\" name=\"q147_haveYou147\" value=\"Yes\" \/><label id=\"label_input_147_0\" for=\"input_147_0\">Yes<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_147\" class=\"form-radio\" id=\"input_147_1\" name=\"q147_haveYou147\" value=\"No\" \/><label id=\"label_input_147_1\" for=\"input_147_1\">No<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_147\" class=\"form-radio\" id=\"input_147_2\" name=\"q147_haveYou147\" value=\"I\u2019m not sure\" \/><label id=\"label_input_147_2\" for=\"input_147_2\">I\u2019m not sure<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_148\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_148\" for=\"input_148\"> Please describe the situation(s) in as much detail as possible, including the names of providers, the facilities where they practice(d) and the consequences for patients, as well as any steps you took. <\/label>\n        <div id=\"cid_148\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_148\" class=\"form-textarea\" name=\"q148_pleaseDescribe148\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_148\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_radio\" id=\"id_150\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_150\" for=\"input_150\"> Have you seen, noticed or heard about a medical device representative or company engaging in behavior that could lead to patient harm? <\/label>\n        <div id=\"cid_150\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_150\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_150\" class=\"form-radio\" id=\"input_150_0\" name=\"q150_haveYou150\" value=\"Yes\" \/><label id=\"label_input_150_0\" for=\"input_150_0\">Yes<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_150\" class=\"form-radio\" id=\"input_150_1\" name=\"q150_haveYou150\" value=\"No\" \/><label id=\"label_input_150_1\" for=\"input_150_1\">No<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_150\" class=\"form-radio\" id=\"input_150_2\" name=\"q150_haveYou150\" value=\"I\u2019m not sure\" \/><label id=\"label_input_150_2\" for=\"input_150_2\">I\u2019m not sure<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_151\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_151\" for=\"input_151\"> Please describe the situation(s) in as much detail as possible, including the names of companies, devices and the tactics used, as well as any steps you took to report the behavior. <\/label>\n        <div id=\"cid_151\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_151\" class=\"form-textarea\" name=\"q151_pleaseDescribe151\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_151\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_125\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_125\" for=\"input_125\"> What is, or was, your title related to your work in this space? <\/label>\n        <div id=\"cid_125\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_125\" class=\"form-textarea\" name=\"q125_whatIs\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_125\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textarea\" id=\"id_126\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_126\" for=\"input_126\"> What is, or was, your day-to-day work like? <\/label>\n        <div id=\"cid_126\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_126\" class=\"form-textarea\" name=\"q126_whatIs107\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_126\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_152\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_152\" for=\"input_152\"> ProPublica specializes in investigative reporting. Is there anything else you would like to share that you think we should know? <\/label>\n        <div id=\"cid_152\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_152\" class=\"form-textarea\" name=\"q152_propublicaSpecializes\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_152\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_108\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_108\" for=\"input_108\"> Do you have any documents you are able to share with us? You can upload them here. <\/label>\n        <div id=\"cid_108\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"jfQuestion-fields\" data-wrapper-react=\"true\">\n            <div class=\"jfField isFilled\">\n              <div class=\"jfUpload-wrapper\">\n                <div class=\"jfUpload-container\">\n                  <div class=\"jfUpload-button-container\">\n                    <div class=\"jfUpload-button\" aria-hidden=\"true\" tabindex=\"0\" style=\"display:none\" data-version=\"v2\">Browse Files<div class=\"jfUpload-heading forDesktop\">Drag and drop files here<\/div>\n                      <div class=\"jfUpload-heading forMobile\">Choose a file<\/div>\n                    <\/div>\n                  <\/div>\n                <\/div>\n                <div class=\"jfUpload-files-container\">\n                  <div class=\"validate[multipleUpload]\"><input type=\"file\" id=\"input_108\" name=\"q108_doYou108[]\" multiple=\"\" class=\"form-upload-multiple\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"\" data-component=\"fileupload\" aria-label=\"Browse Files\" \/><\/div>\n                <\/div>\n              <\/div><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><label class=\"form-sub-label\" for=\"input_108\" id=\"sublabel_input_108\" style=\"min-height:13px\" aria-hidden=\"false\">Collecting evidence is part of our process. Please reach out if you want more information.<\/label><\/span>\n            <\/div><span style=\"display:none\" class=\"cancelText\">Cancel<\/span><span style=\"display:none\" class=\"ofText\">of<\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_44\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_44\" for=\"input_44\"> What\u2019s the best way to reach you with follow-up questions? <\/label>\n        <div id=\"cid_44\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_44\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_44\" class=\"form-checkbox\" id=\"input_44_0\" name=\"q44_whatsThe[]\" value=\"Email\" \/><label id=\"label_input_44_0\" for=\"input_44_0\">Email<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_44\" class=\"form-checkbox\" id=\"input_44_1\" name=\"q44_whatsThe[]\" value=\"Phone\" \/><label id=\"label_input_44_1\" for=\"input_44_1\">Phone<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_44\" class=\"form-checkbox\" id=\"input_44_2\" name=\"q44_whatsThe[]\" value=\"Signal\" \/><label id=\"label_input_44_2\" for=\"input_44_2\">Signal<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_44\" class=\"form-checkbox\" id=\"input_44_3\" name=\"q44_whatsThe[]\" value=\"WhatsApp\" \/><label id=\"label_input_44_3\" for=\"input_44_3\">WhatsApp<\/label><\/span><span class=\"form-checkbox-item formCheckboxOther\" style=\"clear:left\"><input type=\"checkbox\" class=\"form-checkbox-other form-checkbox\" name=\"q44_whatsThe[other]\" id=\"other_44\" value=\"other\" tabindex=\"0\" aria-label=\"Other\" \/><label id=\"label_other_44\" style=\"text-indent:0\" for=\"other_44\">Other<\/label><span id=\"other_44_input\" class=\"other-input-container\" style=\"display:none\"><input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q44_whatsThe[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_44\" data-placeholder=\"Please type another option here\" placeholder=\"Please type another option here\" \/><\/span><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_radio\" id=\"id_68\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_68\" for=\"input_68\"> Do you prefer texts or phone calls? <\/label>\n        <div id=\"cid_68\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_68\" data-component=\"radio\"><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_68\" class=\"form-radio\" id=\"input_68_0\" name=\"q68_typeA\" value=\"I prefer phone calls.\" \/><label id=\"label_input_68_0\" for=\"input_68_0\">I prefer phone calls.<\/label><\/span><span class=\"form-radio-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"radio\" aria-describedby=\"label_68\" class=\"form-radio\" id=\"input_68_1\" name=\"q68_typeA\" value=\"I prefer texts.\" \/><label id=\"label_input_68_1\" for=\"input_68_1\">I prefer texts.<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_phone\" id=\"id_70\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_70\" for=\"input_70_full\"> What's your number on WhatsApp? <\/label>\n        <div id=\"cid_70\" class=\"form-input-wide\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" id=\"input_70_full\" name=\"q70_whatsYour70[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[Fill Mask]\" data-defaultvalue=\"\" autoComplete=\"section-input_70 tel-national\" style=\"width:310px\" data-masked=\"true\" value=\"\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_70\" \/><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_phone\" id=\"id_71\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_71\" for=\"input_71_full\"> What's your Signal number? <\/label>\n        <div id=\"cid_71\" class=\"form-input-wide\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" id=\"input_71_full\" name=\"q71_whatsYour[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[Fill Mask]\" data-defaultvalue=\"\" autoComplete=\"section-input_71 tel-national\" style=\"width:310px\" data-masked=\"true\" value=\"\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_71\" \/><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_82\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_82\" for=\"input_82\"> How did you find this form? I saw it on\/in: <\/label>\n        <div id=\"cid_82\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_82\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_0\" name=\"q82_howDid[]\" value=\"ProPublica\u2019s website\" \/><label id=\"label_input_82_0\" for=\"input_82_0\">ProPublica\u2019s website<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_1\" name=\"q82_howDid[]\" value=\"The Wichita Eagle\" \/><label id=\"label_input_82_1\" for=\"input_82_1\">The Wichita Eagle<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_2\" name=\"q82_howDid[]\" value=\"Another publication\" \/><label id=\"label_input_82_2\" for=\"input_82_2\">Another publication<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_3\" name=\"q82_howDid[]\" value=\"Another forum, newsletter, blog or group I follow\" \/><label id=\"label_input_82_3\" for=\"input_82_3\">Another forum, newsletter, blog or group I follow<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_4\" name=\"q82_howDid[]\" value=\"Facebook\" \/><label id=\"label_input_82_4\" for=\"input_82_4\">Facebook<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_5\" name=\"q82_howDid[]\" value=\"Twitter\" \/><label id=\"label_input_82_5\" for=\"input_82_5\">Twitter<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_6\" name=\"q82_howDid[]\" value=\"Reddit\" \/><label id=\"label_input_82_6\" for=\"input_82_6\">Reddit<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_7\" name=\"q82_howDid[]\" value=\"Instagram\" \/><label id=\"label_input_82_7\" for=\"input_82_7\">Instagram<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_8\" name=\"q82_howDid[]\" value=\"TikTok\" \/><label id=\"label_input_82_8\" for=\"input_82_8\">TikTok<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_9\" name=\"q82_howDid[]\" value=\"Someone sent it to me directly\" \/><label id=\"label_input_82_9\" for=\"input_82_9\">Someone sent it to me directly<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_10\" name=\"q82_howDid[]\" value=\"A ProPublica newsletter\" \/><label id=\"label_input_82_10\" for=\"input_82_10\">A ProPublica newsletter<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_82\" class=\"form-checkbox\" id=\"input_82_11\" name=\"q82_howDid[]\" value=\"Other\" \/><label id=\"label_input_82_11\" for=\"input_82_11\">Other<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_153\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_153\" for=\"input_153\"> Which publication? <\/label>\n        <div id=\"cid_153\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_153\" name=\"q153_whichPublication\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_153\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_154\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_154\" for=\"input_154\"> Which forum, newsletter, blog or group? <\/label>\n        <div id=\"cid_154\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_154\" name=\"q154_whichForum\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_154\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_155\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_155\" for=\"input_155\"> Do you have ideas for getting the word out?\u00a0 Who else should we talk to? <\/label>\n        <div id=\"cid_155\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_155\" name=\"q155_doYou\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_155\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_92\">\n        <div id=\"cid_92\" class=\"form-input-wide\" data-layout=\"full\">\n          <div id=\"text_92\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p><span style=\"font-size: 10pt;\"><em>The following questions are completely optional. ProPublica is committed to maintaining a diverse and representative body of sources. We ask these next questions to understand who we\u2019re reaching and who is affected by the issues we cover.<\/em><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_134\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_134\" for=\"input_134\"> Which race or ethnicity do you identify as? Select all that apply. <\/label>\n        <div id=\"cid_134\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_134\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_0\" name=\"q134_whichRace[]\" value=\"Asian or Asian American\" \/><label id=\"label_input_134_0\" for=\"input_134_0\">Asian or Asian American<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_1\" name=\"q134_whichRace[]\" value=\"Black or African American\" \/><label id=\"label_input_134_1\" for=\"input_134_1\">Black or African American<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_2\" name=\"q134_whichRace[]\" value=\"Hispanic or Latina\/o\/x\" \/><label id=\"label_input_134_2\" for=\"input_134_2\">Hispanic or Latina\/o\/x<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_3\" name=\"q134_whichRace[]\" value=\"Middle Eastern or North African\" \/><label id=\"label_input_134_3\" for=\"input_134_3\">Middle Eastern or North African<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_4\" name=\"q134_whichRace[]\" value=\"Native American or Indigenous\" \/><label id=\"label_input_134_4\" for=\"input_134_4\">Native American or Indigenous<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_5\" name=\"q134_whichRace[]\" value=\"Native Hawaiian or Pacific Islander\" \/><label id=\"label_input_134_5\" for=\"input_134_5\">Native Hawaiian or Pacific Islander<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_6\" name=\"q134_whichRace[]\" value=\"White\" \/><label id=\"label_input_134_6\" for=\"input_134_6\">White<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_134\" class=\"form-checkbox\" id=\"input_134_7\" name=\"q134_whichRace[]\" value=\"Another option not listed\" \/><label id=\"label_input_134_7\" for=\"input_134_7\">Another option not listed<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_132\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_132\" for=\"input_132\"> Please list which race or ethnicity you identify as: <\/label>\n        <div id=\"cid_132\" class=\"form-input-wide\" data-layout=\"half\"> <input type=\"text\" id=\"input_132\" name=\"q132_pleaseList\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_132\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_94\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_94\" for=\"input_94\"> ProPublica works with a trusted network of local and national partners around the country. 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Let us know if you are interested in any of the following: <\/label>\n        <div id=\"cid_95\" class=\"form-input-wide\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_95\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_95\" class=\"form-checkbox\" id=\"input_95_0\" name=\"q95_wouldYou[]\" value=\"Sharing forms (like this one) in community spaces, either online or in person.\" \/><label id=\"label_input_95_0\" for=\"input_95_0\">Sharing forms (like this one) in community spaces, either online or in person.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_95\" class=\"form-checkbox\" id=\"input_95_1\" name=\"q95_wouldYou[]\" value=\"Sharing a reporter\u2019s work or contact information with members of the community.\" \/><label id=\"label_input_95_1\" for=\"input_95_1\">Sharing a reporter\u2019s work or contact information with members of the community.<\/label><\/span><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_95\" class=\"form-checkbox\" id=\"input_95_2\" name=\"q95_wouldYou[]\" value=\"Testing or providing feedback on our journalism early in the process.\" \/><label id=\"label_input_95_2\" for=\"input_95_2\">Testing or providing feedback on our journalism early in the process.<\/label><\/span><span class=\"form-checkbox-item formCheckboxOther\" style=\"clear:left\"><input type=\"checkbox\" class=\"form-checkbox-other form-checkbox\" name=\"q95_wouldYou[other]\" id=\"other_95\" value=\"other\" tabindex=\"0\" aria-label=\"Other\" \/><label id=\"label_other_95\" style=\"text-indent:0\" for=\"other_95\">Other<\/label><span id=\"other_95_input\" class=\"other-input-container\" style=\"display:none\"><input type=\"text\" class=\"form-checkbox-other-input form-textbox\" name=\"q95_wouldYou[other]\" data-otherhint=\"Other\" size=\"15\" id=\"input_95\" data-placeholder=\"Please type another option here\" placeholder=\"Please type another option here\" \/><\/span><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_97\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_97\" for=\"input_97\"> Thank you! 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