{"id":177,"date":"2021-07-08T14:09:57","date_gmt":"2021-07-08T14:09:57","guid":{"rendered":"https:\/\/maxwell.solutions\/phaseone\/?page_id=177"},"modified":"2021-08-13T09:24:04","modified_gmt":"2021-08-13T13:24:04","slug":"covid-19","status":"publish","type":"page","link":"https:\/\/phaseoneelectrical.ca\/index.php\/covid-19\/","title":{"rendered":"Covid-19 Questionnaire"},"content":{"rendered":"

[et_pb_section fb_built=”1″ _builder_version=”4.9.4″ _module_preset=”default” background_color=”#EF233C” background_enable_image=”off”][et_pb_row _builder_version=”4.6.1″ _module_preset=”default”][et_pb_column type=”4_4″ _builder_version=”4.6.1″ _module_preset=”default”][et_pb_text _builder_version=”4.6.1″ _module_preset=”default” header_text_align=”center” header_text_color=”#ffffff” header_font_size=”62px” custom_padding=”100px||100px||false|false”]<\/p>\n

Covid-19 Questionnaire<\/h1>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.9.4″ _module_preset=”default” background_color=”#FFFFFF”][et_pb_row _builder_version=”4.6.1″ _module_preset=”default”][et_pb_column type=”4_4″ _builder_version=”4.6.1″ _module_preset=”default”][et_pb_contact_form use_spam_service=”on” recaptcha_list=”alltechclimateca|alltechclimateca-0″ email=”PhaseONEelectrical@outlook.com” title=”Covid-19 Questionnaire” custom_message=”Covid 19 Submission Form||et_pb_line_break_holder||========================||et_pb_line_break_holder||||et_pb_line_break_holder||%%First_Name%%||et_pb_line_break_holder||%%Last_Name%%||et_pb_line_break_holder||||et_pb_line_break_holder||%%Address%%||et_pb_line_break_holder||%%Address_2%%||et_pb_line_break_holder||%%City%%||et_pb_line_break_holder||%%Province%%||et_pb_line_break_holder||%%Country%%||et_pb_line_break_holder||||et_pb_line_break_holder||Symptoms:||et_pb_line_break_holder||%%symptoms%%||et_pb_line_break_holder||||et_pb_line_break_holder||Travelled outside of Canada in the last 14 Days?||et_pb_line_break_holder||%%travel%%||et_pb_line_break_holder||||et_pb_line_break_holder||Anyone in household been in contact with Covid-19||et_pb_line_break_holder||%%household%%” success_message=”Thank you for completing the Covid-19 Questionnaire” _builder_version=”4.9.10″ _module_preset=”default” hover_enabled=”0″ sticky_enabled=”0″][et_pb_contact_field field_id=”First_Name” field_title=”First Name” _builder_version=”4.9.4″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Last_Name” field_title=”Last Name” _builder_version=”4.9.4″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Address” field_title=”Address Line #1″ _builder_version=”4.9.4″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Address_2″ field_title=”Address Line #2″ required_mark=”off” _builder_version=”4.9.4″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”City” field_title=”City” required_mark=”off” _builder_version=”4.9.4″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Province” field_title=”Province” required_mark=”off” _builder_version=”4.9.4″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Country” field_title=”Country” required_mark=”off” _builder_version=”4.9.4″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”symptoms” field_title=”Do you or anyone in your household have any of the following new or worsening symptoms or signs?” field_type=”radio” radio_options=”%91{%22value%22:%22Fever or chills%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Difficulty breathing or shortness of breath%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Cough%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Sore throat or trouble swallowing%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Runny\/stuffy nose or nasal congestion%22,%22checked%22:0,%22dragID%22:3},{%22value%22:%22Decrease or loss of smell or taste%22,%22checked%22:0,%22dragID%22:4},{%22value%22:%22Nausea, vomiting, diarrhea, abdominal pain%22,%22checked%22:0,%22dragID%22:5},{%22value%22:%22Felling unwell or extreme tiredness%22,%22checked%22:0,%22dragID%22:6},{%22value%22:%22Sore muscles%22,%22checked%22:0,%22dragID%22:7},{%22value%22:%22None of the Above%22,%22checked%22:0,%22dragID%22:8}%93″ fullwidth_field=”on” _builder_version=”4.9.7″ _module_preset=”default”][\/et_pb_contact_field][et_pb_contact_field field_id=”travel” field_title=”Have you or anyone in your household travelled outside of Canada in the last 14 days?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:8},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:9}%93″ fullwidth_field=”on” _builder_version=”4.9.7″ _module_preset=”default”][\/et_pb_contact_field][et_pb_contact_field field_id=”household” field_title=”Have you or anyone in your household been in contact with a confirmed or probable case of COVID-19?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.9.7″ _module_preset=”default”][\/et_pb_contact_field][\/et_pb_contact_form][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"

Covid-19 Questionnaire<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-177","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/pages\/177"}],"collection":[{"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/comments?post=177"}],"version-history":[{"count":5,"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/pages\/177\/revisions"}],"predecessor-version":[{"id":814,"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/pages\/177\/revisions\/814"}],"wp:attachment":[{"href":"https:\/\/phaseoneelectrical.ca\/index.php\/wp-json\/wp\/v2\/media?parent=177"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}