{"id":8429,"date":"2022-03-16T16:55:40","date_gmt":"2022-03-16T23:55:40","guid":{"rendered":"https:\/\/www.qualityhealth.org\/wpsc\/?page_id=8429"},"modified":"2022-03-16T16:55:40","modified_gmt":"2022-03-16T23:55:40","slug":"wpsc-speak-up-award-nomination-form","status":"publish","type":"page","link":"https:\/\/www.qualityhealth.org\/wpsc\/wpsc-speak-up-award-nomination-form\/","title":{"rendered":"WPSC Speak-Up! Award Nomination Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-8430\"><form id=\"wpforms-form-8430\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"8430\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wpsc\/wp-json\/wp\/v2\/pages\/8429\" data-token=\"4fe6d9060bfec321274eb871af4da7a9\" data-token-time=\"1785566367\"><div class=\"wpforms-head-container\"><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-8430-field_12-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"12\"><h3 id=\"wpforms-8430-field_12\">Organization Information<\/h3><\/div><div id=\"wpforms-8430-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_3\">Organization Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8430-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-8430-field_56-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_56\">Organization Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8430-field_56\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][56]\" required><div class=\"wpforms-field-description\">(Street, City, State, Zip)<\/div><\/div><div id=\"wpforms-8430-field_10-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"10\"><h3 id=\"wpforms-8430-field_10\">Nominator Information<\/h3><\/div><div id=\"wpforms-8430-field_13-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"13\"><label class=\"wpforms-field-label\">Nominator Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-8430-field_13\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][13][first]\" required><label for=\"wpforms-8430-field_13\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-8430-field_13-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][13][last]\" required><label for=\"wpforms-8430-field_13-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-8430-field_14-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_14\">Nominator Organizational Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-8430-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-8430-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_15\">Nominator Title\/Position <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8430-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" required><\/div><div id=\"wpforms-8430-field_16-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_16\">Nominator Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-8430-field_16\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][16]\" aria-label=\"Nominator Phone\" required><\/div><div id=\"wpforms-8430-field_17-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"17\"><h3 id=\"wpforms-8430-field_17\">Nominee Information<\/h3><\/div><div id=\"wpforms-8430-field_58-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_58\">Nominee Name(s) <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-8430-field_58\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58]\" required><\/textarea><div class=\"wpforms-field-description\">(First and Last Name) If you have multiple nominees, enter each name on a separate line.<\/div><\/div><div id=\"wpforms-8430-field_59-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_59\">Nominee Organizational Email(s) <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-8430-field_59\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][59]\" required><\/textarea><div class=\"wpforms-field-description\">If you have multiple nominees, enter each email on a separate line and in the same order as the names are written.<\/div><\/div><div id=\"wpforms-8430-field_60-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_60\">Nominee Title\/Position(s) <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-8430-field_60\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][60]\" required><\/textarea><div class=\"wpforms-field-description\">If you have multiple nominees, enter each title\/position on a separate line and in the same order as the names are written.<\/div><\/div><div id=\"wpforms-8430-field_61-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_61\">Nominee Phone(s) <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-8430-field_61\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][61]\" required><\/textarea><div class=\"wpforms-field-description\">If you have multiple nominees, enter each telephone number on a separate line and in the same order as the names are written.<\/div><\/div><div id=\"wpforms-8430-field_24-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"24\"><h3 id=\"wpforms-8430-field_24\">Nomination Questions<\/h3><div class=\"wpforms-field-description\">Please provide answers for the following questions<\/div><\/div><div id=\"wpforms-8430-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_26\">4. What type of adverse event or error was prevented? i.e. medication error, fall, etc. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8430-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" required><\/div><div id=\"wpforms-8430-field_27-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"27\"><label class=\"wpforms-field-label\">5. Did a patient, family member, or advocate speak up or initiate the &quot;good catch&quot;? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_27\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_27_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_27_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_27_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_27_2\">No<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_27_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"I Don&#039;t Know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_27_3\">I Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_62-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"62\"><label class=\"wpforms-field-label\">6. If the nominee(s) hadn&#039;t spoken up, what is the likelihood that this could have ended as a &quot;near miss&quot;? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_62\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_62_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][62][]\" value=\"Very Likely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_62_1\">Very Likely<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_62_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][62][]\" value=\"Likely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_62_2\">Likely<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_62_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][62][]\" value=\"I&#039;m Not Sure\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_62_3\">I'm Not Sure<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_62_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][62][]\" value=\"Unlikely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_62_4\">Unlikely<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_62_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][62][]\" value=\"Very Unlikely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_62_5\">Very Unlikely<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_30-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"30\"><label class=\"wpforms-field-label\">7. If the nominee(s) hadn&#039;t spoken up, do you think that somebody else may have caught this? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_30\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_30_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_30_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_30_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_30_2\">Yes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_30_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][30][]\" value=\"I Don&#039;t Know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_30_3\">I Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_31-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"31\"><label class=\"wpforms-field-label\">8. If the nominee(s) hadn&#039;t spoken up, what is the likelihood that the patient\/resident\/staff would have incurred permanent damage? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_31\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_31_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Very Likely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_31_1\">Very Likely<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_31_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Likely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_31_2\">Likely<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_31_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"I&#039;m Not Sure\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_31_3\">I'm Not Sure<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_31_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Unlikely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_31_4\">Unlikely<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_31_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Very Unlikely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_31_5\">Very Unlikely<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"32\"><label class=\"wpforms-field-label\">9. If the nominee(s) hadn&#039;t spoken up, what is the likelihood that the patient\/resident\/staff could have died? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_32\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_32_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"Very Likely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_32_1\">Very Likely<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_32_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"Likely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_32_2\">Likely<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_32_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"I&#039;m Not Sure\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_32_3\">I'm Not Sure<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_32_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"Unlikely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_32_4\">Unlikely<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_32_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][32][]\" value=\"Very Unlikely\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_32_5\">Very Unlikely<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_34-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"34\"><label class=\"wpforms-field-label\">10. Was the decision to speak up spontaneous or premeditated? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_34\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_34_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][34][]\" value=\"Spontaneous\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_34_1\">Spontaneous<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_34_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][34][]\" value=\"Premeditated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_34_2\">Premeditated<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_34_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][34][]\" value=\"I Don&#039;t Know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_34_3\">I Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_36-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"36\"><label class=\"wpforms-field-label\">11. Would it have been easy to have remained silent? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_36\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_36_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][36][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_36_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_36_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][36][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_36_2\">Yes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_36_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][36][]\" value=\"I Don&#039;t Know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_36_3\">I Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_37-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"37\"><label class=\"wpforms-field-label\">12. Did the nominee(s) encounter barriers to speaking up (such as somebody brushing off their concern)? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_37\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_37_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_37_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_37_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_37_2\">Yes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_37_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"I Don&#039;t Know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_37_3\">I Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_38-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"38\"><label class=\"wpforms-field-label\">13. Was the patient, resident, family or representative informed of the concern? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_38\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_38_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_38_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_38_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_38_2\">Yes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_38_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][38][]\" value=\"I Don&#039;t Know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_38_3\">I Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_39-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"39\"><label class=\"wpforms-field-label\">14. Did the organization make any changes as a result of speaking up? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-8430-field_39\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_39_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_39_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_39_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_39_2\">Yes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8430-field_39_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"I Don&#039;t Know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8430-field_39_3\">I Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-8430-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-8430-field_41\">Please include a description of the event and if appropriate elaborate on all of the above questions. (Omitting any protected health information.) For example: Why wouldn&#039;t somebody else have caught this? Why would someone remain silent? What barriers to speaking up exist in the organization? 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