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complete-registration.html
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<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8" />
<meta http-equiv="X-UA-Compatible" content="IE=edge" />
<meta name="viewport" content="width=device-width, initial-scale=1">
<style media="screen">
.other-question {
overflow: hidden;
transition: height .6s, padding .6s;
}
.other-question.is-hidden {
height: 0 !important;
padding-top: 0 !important;
padding-bottom: 0 !important;
}
.is-hidden {
display: none;
}
</style>
<link rel="stylesheet" href="css/accessible-autocomplete.min.css" />
<title>Model form for completing testing registration - v03</title>
<link rel="stylesheet" href="css/uswds.min.css" />
<link rel="stylesheet" href="css/accessible-autocomplete.min.css" />
</head>
<body>
<script src="js/uswds.min.js"></script>
<script type="text/javascript" src="js/accessible-autocomplete.min.js"></script>
<a class="usa-skipnav" href="#main-content">Skip to main content</a>
<section class="usa-banner" aria-label="Official government website">
<div class="usa-accordion">
<header class="usa-banner__header padding-bottom-2 min-height-none">
<div class="usa-banner__inner">
<div class="grid-col-auto">
<!-- <img class="usa-banner__header-flag" src="img/us_flag_small.png" alt="U.S. flag"> -->
</div>
<div class="">
<h3 class="padding-bottom-0 margin-bottom-0">Form for completing testing registration</h3>
<p class="usa-banner__header-text padding-top-0 margin-top-0 test-clicker margin-right-2">Not functional / For demonstration purposes. To view the form for scheduling a test, <a href="schedule.html">click here</a>.</p>
</div>
</div>
</header>
</div>
</section>
<div class="usa-overlay"></div>
<header class="usa-header usa-header--basic">
<div class="usa-nav-container">
<div class="">
<div class="usa-logo margin-bottom-0" id="basic-logo">
<h1 class="margin-bottom-1">Finish registering for your COVID-19 test</h1>
<p class="margin-top-1 margin-right-2">Fill out this form for each member of your household who will be receiving a test.</p>
</div>
</div>
</div>
</header>
<div id="page-content" class="usa-section padding-top-4 margin-top-0">
<div class="grid-container">
<div class="grid-row grid-gap">
<main class="" id="main-content">
<!-- <div class="usa-alert margin-bottom-8 margin-top-0">
<div class="usa-alert__body">
<p class="usa-alert__text"><b>All sections can be styled to align with our broader communications strategy.</b></p>
<p class="usa-alert__text">This form can be filled out at any point between the test being scheduled and the specimen being collected. For an example of the form to schedule a test, <a href="schedule.html">click here</a>.</p>
</div>
</div> -->
<form class="example-form-content">
<fieldset class="usa-fieldset margin-top-2 padding-bottom-4">
<legend class="usa-legend">Main reason for being tested</legend>
<span class="usa-hint" id="reason-helper-text">Select all that apply</span>
<br/><br/>
<div class="grid-row grid-gap reasons-for-testing">
<div class="usa-checkbox tablet:grid-col-12">
<input class="usa-checkbox__input" id="symptomatic" type="checkbox" name="reason-for-testing" value="symptomatic">
<label class="usa-checkbox__label" for="symptomatic">I have symptoms of Covid-19</label>
<!-- <span class="usa-hint" id="symptomatic-helper-text">I've received authorizato</span> -->
</div>
<div class="usa-checkbox tablet:grid-col-12">
<input class="usa-checkbox__input" id="random-sample" type="checkbox" name="reason-for-testing" value="random-sample">
<label class="usa-checkbox__label" for="random-sample">I was asked to get tested as part of a random sample</label>
<!-- <span class="usa-hint" id="symptomatic-helper-text">I was asked to participate in testing because</span> -->
</div>
<div class="usa-checkbox tablet:grid-col-12">
<input class="usa-checkbox__input" id="sentinel-group" type="checkbox" name="reason-for-testing" value="sentinel-group">
<label class="usa-checkbox__label" for="sentinel-group">I work in a profession that's been asked to get tested</label>
</div>
<div class="usa-checkbox tablet:grid-col-12">
<input class="usa-checkbox__input" id="large-event" type="checkbox" name="reason-for-testing" value="large-event">
<label class="usa-checkbox__label" for="large-event">I attended an event with more than 100 people</label>
</div>
<div class="usa-checkbox tablet:grid-col-12">
<input class="usa-checkbox__input" id="travel" type="checkbox" name="reason-for-testing" value="travel">
<label class="usa-checkbox__label" for="travel">I recently traveled or am about to travel</label>
</div>
<div class="usa-checkbox tablet:grid-col-12">
<input class="usa-checkbox__input" id="been-in-contact" type="checkbox" name="reason-for-testing" value="been-in-contact">
<label class="usa-checkbox__label" for="been-in-contact">I have been in contact with someone who tested positive</label>
</div>
<div class="usa-checkbox tablet:grid-col-12">
<input class="usa-checkbox__input" id="reason-other" type="checkbox" name="reason-for-testing" value="reason-other">
<label class="usa-checkbox__label" for="reason-other">Other</label>
</div>
<div class="usa-checkbox tablet:grid-col-12 padding-bottom-2 other-question is-hidden" id="mailer-id-question">
<label class="usa-label" for="mailer-id">Mailer ID</label>
<span class="usa-hint" id="mailer-id-helper-text">The ID number on your mailer, if available</span>
<input class="usa-input" id="mailer-id" name="mailer-id" type="text" aria-required="false">
</div>
<div class="usa-checkbox tablet:grid-col-12 padding-bottom-2 other-question is-hidden" id="referral-id-question">
<label class="usa-label" for="mailer-id">Referral ID</label>
<span class="usa-hint" id="mailer-id-helper-text">The referral ID number from your doctor, if available</span>
<input class="usa-input" id="mailer-id" name="mailer-id" type="text" aria-required="false">
</div>
<div class="usa-checkbox tablet:grid-col-12 padding-bottom-2 other-question is-hidden" id="other-reason-question">
<label class="usa-label" for="other-reason">Other reason</label>
<!-- <span class="usa-hint" id="other-reason-helper-text">Tell us more about why you're being tested</span> -->
<input class="usa-input" id="other-reason" name="other-reason" type="text" aria-required="false">
</div>
</div>
</fieldset>
<hr class="margin-top-4 margin-bottom-4"/>
<fieldset class="usa-fieldset padding-bottom-4">
<legend class="usa-legend padding-top-2">Name</legend>
<label class="usa-label" for="first-name">First name</label>
<input class="usa-input" id="first-name" name="first-name" type="text" aria-required="true">
<label class="usa-label" for="middle-name">Middle name <span class="usa-hint">(optional)</span></label>
<input class="usa-input" id="middle-name" name="middle-name" type="text">
<label class="usa-label" for="last-name">Last name</label>
<input class="usa-input" id="last-name" name="last-name" type="text" aria-required="true">
</fieldset>
<fieldset class="usa-fieldset padding-bottom-4">
<legend class="usa-legend padding-top-4">Date of birth</legend>
<span class="usa-hint" id="dob-helper-text">For example, 4 28 1986</span>
<div class="usa-memorable-date">
<div class="usa-form-group usa-form-group--month">
<label class="usa-label" for="date_of_birth_1">Month</label>
<input class="usa-input usa-input--inline" aria-describedby="dobHint" id="date_of_birth_1" name="date_of_birth_1" type="text" maxlength="2" pattern="[0-9]*" inputmode="numeric" value="">
</div>
<div class="usa-form-group usa-form-group--day">
<label class="usa-label" for="date_of_birth_2">Day</label>
<input class="usa-input usa-input--inline" aria-describedby="dobHint" id="date_of_birth_2" name="date_of_birth_2" type="text" maxlength="2" pattern="[0-9]*" inputmode="numeric" value="">
</div>
<div class="usa-form-group usa-form-group--year">
<label class="usa-label" for="date_of_birth_3">Year</label>
<input class="usa-input usa-input--inline" aria-describedby="dobHint" id="date_of_birth_3" name="date_of_birth_3" type="text" minlength="4" maxlength="4" pattern="[0-9]*" inputmode="numeric" value="">
</div>
</div>
</fieldset>
<fieldset id="phone-number-question" class="usa-fieldset padding-bottom-4">
<legend class="usa-legend padding-top-4">Phone number</legend>
<span class="usa-hint" id="address-helper-text">We'll use this phone number to provide updates</span>
<label class="usa-label" for="phone-number"></label>
<input class="usa-input" id="phone-number" name="phone-number" type="tel">
</fieldset>
<fieldset id="email-address-question" class="usa-fieldset padding-bottom-4">
<legend class="usa-legend padding-top-4">Email address</legend>
<span class="usa-hint" id="address-helper-text">We'll send a confirmation message to this email address</span>
<div id="email-address-fields">
<label class="usa-label" for="email-address"></label>
<input class="usa-input" id="email-address" name="email-address" type="email">
</div>
<div class="usa-checkbox padding-top-2">
<input class="usa-checkbox__input" id="no-email" type="checkbox" name="no-email" value="no-email">
<label class="usa-checkbox__label" for="no-email">I do not have an email address</label>
</div>
</fieldset>
<hr class="margin-top-4 margin-bottom-4"/>
<fieldset id="address-question" class="usa-fieldset padding-bottom-4 tablet:grid-col-8 desktop:grid-col-6">
<legend class="usa-legend padding-top-4">Address</legend>
<span class="usa-hint" id="address-helper-text">Your household address. This information will help us understand the spread of COVID-19.</span>
<div id="address-fields">
<label class="usa-label" for="address-1">Street address 1</label>
<input class="usa-input" id="address-1" name="address-1" type="text">
<label class="usa-label" for="address-2">Street address 2 <span class="usa-hint">(optional)</span></label>
<input class="usa-input" id="address-2" name="address-2" type="text">
<div class="grid-row grid-gap">
<div class="mobile-lg:grid-col-8">
<label class="usa-label" for="city">City</label>
<input class="usa-input" id="city" name="city" type="text">
</div>
<div class="mobile-lg:grid-col-4">
<label class="usa-label" for="state">State</label>
<select class="usa-select" id="state" name="state">
<option value>- Select -</option>
<!-- start with local states -->
<option value="RI">Rhode Island</option>
<option value="CT">Connecticut</option>
<option value="MA">Massachusetts</option>
<!-- include all states -->
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces Africa</option>
<option value="AE">AE - Armed Forces Canada</option>
<option value="AE">AE - Armed Forces Europe</option>
<option value="AE">AE - Armed Forces Middle East</option>
<option value="AP">AP - Armed Forces Pacific</option>
</select>
</div>
</div>
<label class="usa-label" for="zip">ZIP</label>
<input class="usa-input usa-input--medium" id="zip" name="zip" type="text" pattern="[\d]{5}(-[\d]{4})?">
</div>
<div class="usa-checkbox padding-top-4">
<input class="usa-checkbox__input" id="no-address" type="checkbox" name="no-address" value="no-address">
<label class="usa-checkbox__label" for="no-address">I do not currently have an address</label>
</div>
</fieldset>
<fieldset id="household-information" class="usa-fieldset padding-bottom-4">
<legend class="usa-legend padding-top-4">How many people live in your household?</legend>
<label class="usa-label" for="household-number">Number of people living in your home</label>
<input class="usa-input" style="width: 100px;" id="household-number" name="household-number" type="text" maxlength="6" size="6">
<div class="usa-checkbox padding-top-4">
<input class="usa-checkbox__input" id="household-group-home" type="checkbox" name="household-information" value="household-group-home">
<label class="usa-checkbox__label" for="household-group-home">I live in a treatment facility, group home, or other group setting</label>
</div>
<div class="usa-checkbox padding-top-1">
<input class="usa-checkbox__input" id="household-dorm-hotel-apartment" type="checkbox" name="household-information" value="household-dorm-hotel-apartment">
<label class="usa-checkbox__label" for="household-dorm-hotel-apartment">I live in a dorm, hotel, or apartment building</label>
</div>
<div class="usa-checkbox padding-top-1">
<input class="usa-checkbox__input" id="household-military-barrack-or-ship" type="checkbox" name="household-information" value="household-military-barrack-or-ship">
<label class="usa-checkbox__label" for="household-military-barrack-or-ship">I live in a military barrack or ship</label>
</div>
</fieldset>
<hr class="margin-top-4 margin-bottom-4"/>
<fieldset id="insurance-information" class="usa-fieldset padding-bottom-2 insurance-info desktop:grid-col-8">
<legend class="usa-legend padding-top-4">Insurance information</legend>
<span class="usa-hint" id="address-helper-text">COVID-19 testing is currently covered by all insurance companies. If you have insurance, you please enter the information here. If you do not currently have insurance, testing is free at locations managed by the State of Rhode Island.</span>
<div class="insurance-info-block padding-bottom-2" id="insurance-provider-1">
<label class="usa-label" for="provider-name">Health insurance provider name</label>
<input class="usa-input" id="provider-name" name="provider-name" type="text">
<label class="usa-label" for="insurance-id-number">ID Number</label>
<input class="usa-input" id="insurance-id-number" name="insurance-id-number" type="text">
<label class="usa-label" for="policy-holder-name">Insurance policyholder's name</label>
<input class="usa-input" id="policy-holder-name" name="policy-holder-name" type="text">
<div class="mobile-lg:grid-col-6">
<label class="usa-label" for="policyholder-relationship">Relationship to policyholder</label>
<select class="usa-select" id="policyholder-relationship" name="policyholder-relationship">
<option value>- Select one -</option>
<option value="self">Self</option>
<option value="parent">Parent</option>
<option value="child">Child</option>
<option value="spouse">Spouse</option>
<option value="domestic-partner">Domestic partner</option>
<option value="custodial-adult">Custodial adult</option>
<option value="other-relationship">Other</option>
</select>
</div>
</div>
<div class="usa-checkbox padding-top-2">
<input class="usa-checkbox__input" id="no-health-insurance" type="checkbox" name="no-health-insurance" value="no-health-insurance">
<label class="usa-checkbox__label" for="no-health-insurance">I do not have health insurance</label>
</div>
<div class="usa-checkbox padding-top-0 additional-insurance-question">
<input class="usa-checkbox__input" id="additional-health-insurance" type="checkbox" name="additional-health-insurance" value="additional-health-insurance">
<label class="usa-checkbox__label" for="additional-health-insurance">I have an additional health insurance provider</label>
</div>
</fieldset>
<fieldset class="usa-fieldset padding-bottom-2 insurance-info desktop:grid-col-8 other-question is-hidden" id="insurance-provider-2">
<legend class="usa-legend padding-top-4">Additional insurance provider</legend>
<span class="usa-hint" id="address-helper-text">Enter the information for your additional health insurance provider below</span>
<div class="insurance-info-block">
<label class="usa-label" for="provider-name-2">Health insurance provider name</label>
<input class="usa-input" id="provider-name-2" name="provider-name-2" type="text">
<label class="usa-label" for="insurance-id-number-2">ID Number</label>
<input class="usa-input" id="insurance-id-number-2" name="insurance-id-number-2" type="text">
<label class="usa-label" for="policy-holder-name-2">Insurance policyholder's name</label>
<input class="usa-input" id="policy-holder-name-2" name="policy-holder-name-2" type="text">
<div class="mobile-lg:grid-col-6">
<label class="usa-label" for="policyholder-relationship-2">Relationship to policyholder</label>
<select class="usa-select" id="policyholder-relationship-2" name="policyholder-relationship-2">
<option value>- Select one -</option>
<option value="self-2">Self</option>
<option value="parent-2">Parent</option>
<option value="child-2">Child</option>
<option value="spouse-2">Spouse</option>
<option value="domestic-partner-2">Domestic partner</option>
<option value="custodial-adult-2">Custodial adult</option>
<option value="other-relationship-2">Other</option>
</select>
</div>
</div>
</fieldset>
<hr class="margin-top-6 margin-bottom-4"/>
<fieldset id="pcp-question" class="usa-fieldset padding-bottom-4 insurance-info">
<legend class="usa-legend padding-top-4">Primary Care Provider</legend>
<span class="usa-hint" id="pcp-helper-text">If you have a primary care doctor, search for their name below</span>
<div id="pcp-fields" class="padding-top-2 margin-bottom-4">
<div class="usa-checkbox tablet:grid-col-9">
<select class="usa-input" id="PCP-name" name="PCP-name" type="text" aria-required="false">
<option value="no-pcp-selected"></option>
</select>
</div>
</div>
<div class="usa-checkbox pcp-not-found-checkbox">
<input class="usa-checkbox__input" id="pcp-not-found" type="checkbox" name="pcp-not-found" value="pcp-not-found">
<label class="usa-checkbox__label" for="pcp-not-found">I am not able to find my Primary Care Provider in this list</label>
</div>
<div class="usa-checkbox no-pcp-checkbox">
<input class="usa-checkbox__input" id="no-pcp" type="checkbox" name="no-pcp" value="no-pcp">
<label class="usa-checkbox__label" for="no-pcp">I do not have a Primary Care Provider</label>
</div>
</fieldset>
<hr class="margin-top-4 margin-bottom-8"/>
<fieldset id="symptoms-24-hours-question" class="usa-fieldset padding-bottom-8">
<legend class="usa-legend">What symptoms have you experienced in the past 24 hours?</legend>
<span class="usa-hint" id="symptoms-helper-text">Select all that apply</span>
<br/><br/>
<div class="grid-row grid-gap">
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="cough-24-hours" type="checkbox" name="symptoms-24-hours" value="cough-24-hours">
<label class="usa-checkbox__label" for="cough-24-hours">Cough</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="fever-24-hours" type="checkbox" name="symptoms-24-hours" value="fever-24-hours">
<label class="usa-checkbox__label" for="fever-24-hours">Fever or chills</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="body-aches-24-hours" type="checkbox" name="symptoms-24-hours" value="body-aches-24-hours">
<label class="usa-checkbox__label" for="body-aches-24-hours">Muscle or body aches</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="sore-throat-24-hours" type="checkbox" name="symptoms-24-hours" value="sore-throat-24-hours">
<label class="usa-checkbox__label" for="sore-throat-24-hours">Sore throat</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="headache-24-hours" type="checkbox" name="symptoms-24-hours" value="headache-24-hours">
<label class="usa-checkbox__label" for="headache-24-hours">Headache</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="nausea-vomiting-24-hours" type="checkbox" name="symptoms-24-hours" value="nausea-vomiting-24-hours">
<label class="usa-checkbox__label" for="nausea-vomiting-24-hours">Nausea or vomiting</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="diarrhea-24-hours" type="checkbox" name="symptoms-24-hours" value="diarrhea-24-hours">
<label class="usa-checkbox__label" for="diarrhea-24-hours">Diarrhea</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="runny-nose-24-hours" type="checkbox" name="symptoms-24-hours" value="runny-nose-24-hours">
<label class="usa-checkbox__label" for="runny-nose-24-hours">Runny nose or stuffy nose</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="fatigue-24-hours" type="checkbox" name="symptoms-24-hours" value="fatigue-24-hours">
<label class="usa-checkbox__label" for="fatigue-24-hours">Fatigue</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="loss-taste-smell-24-hours" type="checkbox" name="symptoms-24-hours" value="loss-taste-smell-24-hours">
<label class="usa-checkbox__label" for="loss-taste-smell-24-hours">Loss of taste or smell</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="symptoms-24-hours-other" type="checkbox" name="symptoms-24-hours" value="symptoms-24-hours-other">
<label class="usa-checkbox__label" for="symptoms-24-hours-other">Other</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="current-symptoms-no-symptoms" type="checkbox" name="symptoms-24-hours" value="current-symptoms-no-symptoms">
<label class="usa-checkbox__label" for="current-symptoms-no-symptoms">I have not experienced symptoms</label>
</div>
</div>
<div class="usa-checkbox tablet:grid-col-12 padding-bottom-2 other-question is-hidden" id="other-symptoms-24-hours-question">
<label class="usa-label" for="other-symptoms-24-hours">What other symptoms have you experienced in the past 24 hours? </label>
<input class="usa-input" id="other-symptoms-24-hours" name="other-symptoms-24-hours" type="text" aria-required="false">
</div>
<div class="usa-form-group is-hidden" id="current-symptoms-onset-date-question">
<label class="usa-label" id="current-symptoms-onset-date-label" for="current-symptoms-onset-date">On what day did you begin experiencing symptoms?</label>
<div class="usa-hint" id="current-symptoms-onset-date-hint">Use format mm/dd/yyyy</div>
<div class="usa-date-picker">
<input class="usa-input" id="current-symptoms-onset-date" name="current-symptoms-onset-date" type="text" aria-describedby="current-symptoms-onset-date-label current-symptoms-onset-date-hint">
</div>
</div>
</fieldset>
<fieldset id="symptoms-march-2020" class="usa-fieldset margin-top-2 padding-bottom-8">
<legend class="usa-legend">What symptoms have you experienced since March 1st, 2020?</legend>
<span class="usa-hint" id="symptoms-helper-text">Select all that apply</span>
<br/><br/>
<div class="grid-row grid-gap">
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="cough-march-2020" type="checkbox" name="symptoms-march-2020" value="cough-march-2020">
<label class="usa-checkbox__label" for="cough-march-2020">Cough</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="fever-march-2020" type="checkbox" name="symptoms-march-2020" value="fever-march-2020">
<label class="usa-checkbox__label" for="fever-march-2020">Fever or chills</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="body-aches-march-2020" type="checkbox" name="symptoms-march-2020" value="body-aches-march-2020">
<label class="usa-checkbox__label" for="body-aches-march-2020">Muscle or body aches</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="sore-throat-march-2020" type="checkbox" name="symptoms-march-2020" value="sore-throat-march-2020">
<label class="usa-checkbox__label" for="sore-throat-march-2020">Sore throat</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="headache-march-2020" type="checkbox" name="symptoms-march-2020" value="headache-march-2020">
<label class="usa-checkbox__label" for="headache-march-2020">Headache</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="nausea-vomiting-march-2020" type="checkbox" name="symptoms-march-2020" value="nausea-vomiting-march-2020">
<label class="usa-checkbox__label" for="nausea-vomiting-march-2020">Nausea or vomiting</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="diarrhea-march-2020" type="checkbox" name="symptoms-march-2020" value="diarrhea-march-2020">
<label class="usa-checkbox__label" for="diarrhea-march-2020">Diarrhea</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="runny-nose-march-2020" type="checkbox" name="symptoms-march-2020" value="runny-nose-march-2020">
<label class="usa-checkbox__label" for="runny-nose-march-2020">Runny nose or stuffy nose</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="fatigue-march-2020" type="checkbox" name="symptoms-march-2020" value="fatigue-march-2020">
<label class="usa-checkbox__label" for="fatigue-march-2020">Fatigue</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="loss-taste-smell-march-2020" type="checkbox" name="symptoms-march-2020" value="loss-taste-smell-march-2020">
<label class="usa-checkbox__label" for="loss-taste-smell-march-2020">Loss of taste or smell</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="symptoms-march-2020-other" type="checkbox" name="symptoms-march-2020" value="symptoms-march-2020-other">
<label class="usa-checkbox__label" for="symptoms-march-2020-other">Other</label>
</div>
<div class="usa-checkbox tablet:grid-col-3">
<input class="usa-checkbox__input" id="symptoms-march-2020-no-symptoms" type="checkbox" name="symptoms-march-2020" value="symptoms-march-2020-no-symptoms">
<label class="usa-checkbox__label" for="symptoms-march-2020-no-symptoms">I have not experienced symptoms</label>
</div>
</div>
<div class="usa-checkbox tablet:grid-col-12 padding-bottom-2 other-question is-hidden" id="other-symptoms-march-2020-question">
<label class="usa-label" for="other-symptoms-march-2020">What other symptoms have you experienced since March 1st, 2020?</label>
<input class="usa-input" id="other-symptoms-march-2020" name="other-symptoms-march-2020" type="text" aria-required="false">
</div>
<div class="usa-form-group is-hidden" id="march-2020-symptoms-onset-date-question">
<label class="usa-label" id="march-2020-symptoms-onset-date-label" for="march-2020-symptoms-onset-date">On what day did you begin experiencing symptoms?</label>
<div class="usa-hint" id="march-2020-symptoms-onset-date-hint">Use format mm/dd/yyyy</div>
<div class="usa-date-picker">
<input class="usa-input" id="march-2020-symptoms-onset-date" name="march-2020-symptoms-onset-date" type="text" aria-describedby="march-2020-symptoms-onset-date-label march-2020-symptoms-onset-date-hint">
</div>
</div>
</fieldset>
<fieldset id="around-someone-who-tested-positive" class="usa-fieldset padding-bottom-8 margin-top-2 random-sample-questions" id="positive-nearby">
<legend class="usa-legend">Have you been around someone who tested positive?</legend>
<!-- <span class="usa-hint" id="symptoms-helper-text"></span> -->
<br/>
<div class="grid-row grid-gap">
<div class="usa-radio tablet:grid-col-3">
<input class="usa-radio__input" id="yes-around-someone" type="radio" name="around-someone" value="yes-mailer">
<label class="usa-radio__label" for="yes-around-someone">Yes, I have</label>
</div>
<div class="usa-radio tablet:grid-col-3">
<input class="usa-radio__input" id="no-around-someone" type="radio" name="around-someone" value="no-around-someone">
<label class="usa-radio__label" for="no-around-someone">No, I have not</label>
</div>
</div>
</fieldset>
<fieldset id="recent-locations" class="usa-fieldset padding-bottom-4">
<legend class="usa-legend">Have you spent more than 15 minutes at any of these types of places in the past two weeks?</legend>
<span class="usa-hint display-block margin-top-1" id="recent-locations-helper-text">Select all that apply, as this helps us understand the spread of COVID-19</span>
<br/>
<div class="grid-row grid-gap">
<div id="medical-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Medical settings</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-hospital" type="checkbox" name="recent-locations" value="recent-location-hospital">
<label class="usa-checkbox__label" for="recent-location-hospital">Hospital</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-health-clinic" type="checkbox" name="recent-locations" value="recent-location-health-clinic">
<label class="usa-checkbox__label" for="recent-location-health-clinic">Health clinic or doctor's office</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-dental-office" type="checkbox" name="recent-locations" value="recent-location-dental-office">
<label class="usa-checkbox__label" for="recent-location-dental-office">Dental office</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-physical-therapy" type="checkbox" name="recent-locations" value="recent-location-physical-therapy">
<label class="usa-checkbox__label" for="recent-location-physical-therapy">Physical therapy or chiropractic</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-other-specialist" type="checkbox" name="recent-locations" value="recent-location-other-specialist">
<label class="usa-checkbox__label" for="recent-location-other-specialist">Other specialist</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-" type="checkbox" name="recent-locations" value="recent-location-">
<label class="usa-checkbox__label" for="recent-location-">I receive home health, hospice, or other in-home services (for example, meals on wheels)</label>
</div>
</div>
<div id="educational-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Educational settings</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-childcare" type="checkbox" name="recent-locations" value="recent-location-childcare">
<label class="usa-checkbox__label" for="recent-location-childcare">Childcare</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-summer-camp" type="checkbox" name="recent-locations" value="recent-location-summer-camp">
<label class="usa-checkbox__label" for="recent-location-summer-camp">Summer camp</label>
</div>
<div class="usa-checkbox padding-right-2">
<input class="usa-checkbox__input" id="recent-location-k12-school" type="checkbox" name="recent-locations" value="recent-location-k12-school">
<label class="usa-checkbox__label" for="recent-location-k12-school">Kindergarten, Elementary, Middle, or High School</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-college-university" type="checkbox" name="recent-locations" value="recent-location-college-university">
<label class="usa-checkbox__label" for="recent-location-college-university">College or university</label>
</div>
</div>
<div id="congregate-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Congregate or temporary housing</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-hotel-or-other-lodging" type="checkbox" name="recent-locations" value="recent-location-hotel-or-other-lodging">
<label class="usa-checkbox__label" for="recent-location-hotel-or-other-lodging">Hotel, short-term rental, or other lodging</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-apartment-complex-public-housing" type="checkbox" name="recent-locations" value="recent-location-apartment-complex-public-housing">
<label class="usa-checkbox__label" for="recent-location-apartment-complex-public-housing">Apartment complex or public housing</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-nursing-or-group-home" type="checkbox" name="recent-locations" value="recent-location-nursing-or-group-home">
<label class="usa-checkbox__label" for="recent-location-nursing-or-group-home">Nursing home, Assisted living, or Group home</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-shelter-cooling-center" type="checkbox" name="recent-locations" value="recent-location-shelter-cooling-center">
<label class="usa-checkbox__label" for="recent-location-shelter-cooling-center">Shelter or cooling center</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-correctional-facility" type="checkbox" name="recent-locations" value="recent-location-correctional-facility">
<label class="usa-checkbox__label" for="recent-location-correctional-facility">Correctional facility</label>
</div>
</div>
</div> <!-- end row 1 -->
<div class="grid-row grid-gap padding-top-2">
<div id="customer-service-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Customer service settings</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-personal-services" type="checkbox" name="recent-locations" value="recent-location-personal-services">
<label class="usa-checkbox__label" for="recent-location-personal-services">Personal services (Nail, Massage, Tattoo, Facialist, Hair salon, Barbershop)</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-laundromat" type="checkbox" name="recent-locations" value="recent-location-laundromat">
<label class="usa-checkbox__label" for="recent-location-laundromat">Laundromat</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-personal-business" type="checkbox" name="recent-locations" value="recent-location-personal-business">
<label class="usa-checkbox__label" for="recent-location-personal-business">Personal business (Banking, Financial, Legal)</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-real-estate-open-house" type="checkbox" name="recent-locations" value="recent-location-real-estate-open-house">
<label class="usa-checkbox__label" for="recent-location-real-estate-open-house">Real estate open house</label>
</div>
</div>
<div id="food-or-retail-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Food and retail settings</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-restaurant-bar-indoors" type="checkbox" name="recent-locations" value="recent-location-restaurant-bar-indoors">
<label class="usa-checkbox__label" for="recent-location-restaurant-bar-indoors">Restaurant or bar, indoors</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-restaurant-bar-outdoors" type="checkbox" name="recent-locations" value="recent-location-restaurant-bar-outdoors">
<label class="usa-checkbox__label" for="recent-location-restaurant-bar-outdoors">Restaurant or bar, outdoors</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-grocery-store-indoors" type="checkbox" name="recent-locations" value="recent-location-grocery-store-indoors">
<label class="usa-checkbox__label" for="recent-location-grocery-store-indoors">Grocery store, indoors</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-farmers-market-outdoor-grocery" type="checkbox" name="recent-locations" value="recent-location-farmers-market-outdoor-grocery">
<label class="usa-checkbox__label" for="recent-location-farmers-market-outdoor-grocery">Farmer’s market or outdoor grocery</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-garden-center-nursery" type="checkbox" name="recent-locations" value="recent-location-garden-center-nursery">
<label class="usa-checkbox__label" for="recent-location-garden-center-nursery">Garden center or nursery</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-retail-or-shopping-mall" type="checkbox" name="recent-locations" value="recent-location-retail-or-shopping-mall">
<label class="usa-checkbox__label" for="recent-location-retail-or-shopping-mall">Retail store or shopping mall</label>
</div>
</div>
<div id="transportation-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Transportation</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-bus-train-shuttle" type="checkbox" name="recent-locations" value="recent-location-bus-train-shuttle">
<label class="usa-checkbox__label" for="recent-location-bus-train-shuttle">Bus, train, or shuttle</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-ferry-boat" type="checkbox" name="recent-locations" value="recent-location-ferry-boat">
<label class="usa-checkbox__label" for="recent-location-ferry-boat">Ferry or boat</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-rideshare-taxi" type="checkbox" name="recent-locations" value="recent-location-rideshare-taxi">
<label class="usa-checkbox__label" for="recent-location-rideshare-taxi">Rideshare or taxi</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-shared-vehicle-carpool" type="checkbox" name="recent-locations" value="recent-location-shared-vehicle-carpool">
<label class="usa-checkbox__label" for="recent-location-shared-vehicle-carpool">Shared vehicle or carpool</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-airplane-airport" type="checkbox" name="recent-locations" value="recent-location-airplane-airport">
<label class="usa-checkbox__label" for="recent-location-airplane-airport">Airplane or airport</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-ems-ambulance-rescue" type="checkbox" name="recent-locations" value="recent-location-ems-ambulance-rescue">
<label class="usa-checkbox__label" for="recent-location-ems-ambulance-rescue">Emergency medical transportation (Ambulance, rescue)</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-traveled-outside-ri" type="checkbox" name="recent-locations" value="recent-location-traveled-outside-ri">
<label class="usa-checkbox__label" for="recent-location-traveled-outside-ri">I have traveled outside of Rhode Island</label>
</div>
</div>
</div> <!-- end row 2 -->
<div class="grid-row grid-gap padding-top-2">
<div id="recreation-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Recreation settings</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-beach-or-public-pool" type="checkbox" name="recent-locations" value="recent-location-beach-or-public-pool">
<label class="usa-checkbox__label" for="recent-location-beach-or-public-pool">Beach or public pool</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-park-garden" type="checkbox" name="recent-locations" value="recent-location-park-garden">
<label class="usa-checkbox__label" for="recent-location-park-garden">Outdoor park or garden</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-amusement-park" type="checkbox" name="recent-locations" value="recent-location-amusement-park">
<label class="usa-checkbox__label" for="recent-location-amusement-park">Amusement park</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-outdoor-sports-field-or-court" type="checkbox" name="recent-locations" value="recent-location-outdoor-sports-field-or-court">
<label class="usa-checkbox__label" for="recent-location-outdoor-sports-field-or-court">Outdoor sports field or court</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-gym-fitness-sports" type="checkbox" name="recent-locations" value="recent-location-gym-fitness-sports">
<label class="usa-checkbox__label" for="recent-location-gym-fitness-sports">Gym, fitness class, or sports team</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-other-group-lesson" type="checkbox" name="recent-locations" value="recent-location-other-group-lesson">
<label class="usa-checkbox__label" for="recent-location-other-group-lesson">Other group lesson or class</label>
</div>
</div>
<div id="civic-religious-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Civic and religious settings</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-church-or-place-of-worship" type="checkbox" name="recent-locations" value="recent-location-church-or-place-of-worship">
<label class="usa-checkbox__label" for="recent-location-church-or-place-of-worship">Church or place of worship</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-museum-library-recreation-center" type="checkbox" name="recent-locations" value="recent-location-museum-library-recreation-center">
<label class="usa-checkbox__label" for="recent-location-museum-library-recreation-center">Museum, library, or recreation center</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-government-office-or-courthouse" type="checkbox" name="recent-locations" value="recent-location-government-office-or-courthouse">
<label class="usa-checkbox__label" for="recent-location-government-office-or-courthouse">Government office or courthouse</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-senior-center" type="checkbox" name="recent-locations" value="recent-location-senior-center">
<label class="usa-checkbox__label" for="recent-location-senior-center">Senior center</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input" id="recent-location-voting-location" type="checkbox" name="recent-locations" value="recent-location-voting-location">
<label class="usa-checkbox__label" for="recent-location-voting-location">Voting location</label>
</div>
</div>
<div id="gathering-setting-options" class="tablet:grid-col">
<h3 class="margin-bottom-2">Gatherings and events</h3>
<div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-protest-or-rally" type="checkbox" name="recent-locations" value="recent-location-protest-or-rally">
<label class="usa-checkbox__label" for="recent-location-protest-or-rally">Protest or rally</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-concert-or-entertainment" type="checkbox" name="recent-locations" value="recent-location-concert-or-entertainment">
<label class="usa-checkbox__label" for="recent-location-concert-or-entertainment">Concert or entertainment</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-wedding-or-funeral" type="checkbox" name="recent-locations" value="recent-location-wedding-or-funeral">
<label class="usa-checkbox__label" for="recent-location-wedding-or-funeral">Wedding or funeral</label>
</div>
<!-- <div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-wedding" type="checkbox" name="recent-locations" value="recent-location-wedding">
<label class="usa-checkbox__label" for="recent-location-wedding">Wedding</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-funeral" type="checkbox" name="recent-locations" value="recent-location-funeral">
<label class="usa-checkbox__label" for="recent-location-funeral">Funeral</label>
</div> -->
<div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-cookout-barbecue" type="checkbox" name="recent-locations" value="recent-location-cookout-barbecue">
<label class="usa-checkbox__label" for="recent-location-cookout-barbecue">Cookout or barbecue</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-graduation-or-other-life-event" type="checkbox" name="recent-locations" value="recent-location-graduation-or-other-life-event">
<label class="usa-checkbox__label" for="recent-location-graduation-or-other-life-event">Graduation or other life event (baby shower, etc)</label>
</div>
<div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-other-gathering-more-than-25" type="checkbox" name="recent-locations" value="recent-location-other-gathering-more-than-25">
<label class="usa-checkbox__label" for="recent-location-other-gathering-more-than-25">Other gathering of more than 25 people</label>
</div>
<!-- <div class="usa-checkbox">
<input class="usa-checkbox__input gathering-question" id="recent-location-other-gathering-more-than-50" type="checkbox" name="recent-locations" value="recent-location-other-gathering-more-than-50">
<label class="usa-checkbox__label" for="recent-location-other-gathering-more-than-50">Other gathering of more than 50 people</label>
</div> -->
</div>
</div> <!-- end row 3 -->
<div id="gathering-question-indoors" class="is-hidden">
<div class="grid-row grid-gap padding-top-2">
<h3 class="display-block tablet:grid-col-12">Were the gatherings or events indoors or outdoors?</h3>
<!-- <span class="usa-hint" id="gathering-helper-text"></span> -->
<br/>
<div class="grid-row grid-gap">
<div class="usa-radio tablet:grid-col-12">
<input class="usa-radio__input" id="gathering-indoors-yes" type="radio" name="gathering-indoors-question" value="gathering-indoors-yes">
<label class="usa-radio__label" for="gathering-indoors-yes">Indoors</label>
</div>
<div class="usa-radio tablet:grid-col-12">
<input class="usa-radio__input" id="gathering-indoors-no" type="radio" name="gathering-indoors-question" value="gathering-indoors-no">
<label class="usa-radio__label" for="gathering-indoors-no">Outdoors</label>
</div>
<div class="usa-radio tablet:grid-col-12">
<input class="usa-radio__input" id="gathering-indoors-both" type="radio" name="gathering-indoors-question" value="gathering-indoors-both">
<label class="usa-radio__label" for="gathering-indoors-both">Both</label>
</div>
</div>
</div>
</div> <!-- end optional row 4 -->
<div class="usa-checkbox tablet:grid-col-12 padding-bottom-2 other-question is-hidden" id="other-symptoms-2-question">
<label class="usa-label" for="other-symptoms-2">What other symptoms have you experienced since March 1st, 2020?</label>
<input class="usa-input" id="other-symptoms-2" name="other-symptoms-2" type="text" aria-required="false">
</div>
</fieldset>
<hr class="margin-top-4 margin-bottom-8"/>
<fieldset class="usa-fieldset padding-bottom-4" id="work-setting">
<legend class="usa-legend">What setting do you currently work in?</legend>
<span class="usa-hint" id="work-setting-helper-text">Select the option that best describes where you work</span>
<br/><br/>
<div class="grid-row grid-gap">
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="work-setting-notworking" type="radio" name="work-setting" value="work-setting-notworking">
<label class="usa-radio__label" for="work-setting-notworking">Currently not working</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="healthcare" type="radio" name="work-setting" value="healthcare">
<label class="usa-radio__label" for="healthcare">Healthcare</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="dental" type="radio" name="work-setting" value="dental">
<label class="usa-radio__label" for="dental">Dental</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="childcare" type="radio" name="work-setting" value="childcare">
<label class="usa-radio__label" for="childcare">Childcare</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="congregate-living" type="radio" name="work-setting" value="congregate-living">
<label class="usa-radio__label" for="congregate-living">Congregate living (Nursing home, Assisted living, Group home)</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="faith-based-organization" type="radio" name="work-setting" value="faith-based-organization">
<label class="usa-radio__label" for="faith-based-organization">Faith-based organization</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="gym" type="radio" name="work-setting" value="gym">
<label class="usa-radio__label" for="gym">Gym</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="hair-salon-barbershop" type="radio" name="work-setting" value="hair-salon-barbershop">
<label class="usa-radio__label" for="hair-salon-barbershop">Hair Salon or Barbershop</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="personal-services" type="radio" name="work-setting" value="personal-services">
<label class="usa-radio__label" for="personal-services">Personal services (Nail, Massage, Tattoo, Facialist, Other)</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="physical-therapy" type="radio" name="work-setting" value="physical-therapy">
<label class="usa-radio__label" for="physical-therapy">Physical therapy or Chiropractic</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="restaurant-or-bar" type="radio" name="work-setting" value="restaurant-or-bar">
<label class="usa-radio__label" for="restaurant-or-bar">Restaurant or Bar</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="grocery-store" type="radio" name="work-setting" value="grocery-store">
<label class="usa-radio__label" for="grocery-store">Grocery store</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="retail" type="radio" name="work-setting" value="retail">
<label class="usa-radio__label" for="retail">Retail</label>
</div>
<div class="usa-radio tablet:grid-col-6 padding-bottom-1">
<input class="usa-radio__input" id="construction-trades" type="radio" name="work-setting" value="construction-trades">