{"id":2216,"date":"2025-09-15T14:08:43","date_gmt":"2025-09-15T14:08:43","guid":{"rendered":"https:\/\/hopeforckd.com\/testing-form\/"},"modified":"2025-09-15T14:11:03","modified_gmt":"2025-09-15T14:11:03","slug":"testing-form","status":"publish","type":"page","link":"https:\/\/hopeforckd.com\/es\/testing-form\/","title":{"rendered":"TEsting Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2216\" class=\"elementor elementor-2216 elementor-2211\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4197d71 e-flex e-con-boxed e-con e-parent\" data-id=\"4197d71\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b4e1ec6 elementor-widget elementor-widget-html\" data-id=\"b4e1ec6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Bienvenido a la encuesta del estudio PROACT 1<\/h2>\n                            <p class='gform_description'>Gracias por su inter\u00e9s en el estudio PROACT 1. Esta encuesta nos ayudar\u00e1 a averiguar si puede participar en el estudio y cu\u00e1l es el centro de estudio m\u00e1s cercano a su domicilio. Lea atentamente cada pregunta y responda lo mejor que pueda. Esta encuesta tambi\u00e9n tiene una secci\u00f3n para que usted diga que est\u00e1 de acuerdo en compartir su informaci\u00f3n personal (PII).   <\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/es\/wp-json\/wp\/v2\/pages\/2216' data-formid='2' novalidate><input type=\"hidden\" name=\"gpuid_existing_value_101\" id=\"gpuid_existing_value_101\" value=\"1f9f982656ee1150dee267547d58c947\" \/>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_119\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_119'>Phone<\/label><div class='ginput_container'><input name='input_119' id='input_2_119' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_119'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><h3 class=\"gsection_title\">About Proact 1 Study Pre-Screening Survey<\/h3><div class='gsection_description' id='gfield_description_2_15'>This will be a pre-screening survey on the site that will allow us to filter through people who are not eligible and then we will forward those who have \u201cpassed\u201d non-eligibility screener to the study sites for additional eligibility screening.<\/div><\/div><div id=\"field_2_22\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consentimiento informado<\/h3><div class='gsection_description' id='gfield_description_2_22'>Consentimiento informado significa aceptar que utilicemos sus datos personales. Al marcar la casilla siguiente, acepta compartir su informaci\u00f3n personal identificable (IPI) con el equipo del estudio PROACT 1. Sus datos s\u00f3lo se utilizar\u00e1n para ver si puede participar en el estudio y encontrar el mejor lugar para usted en funci\u00f3n de su lugar de residencia. Algunas enfermedades transmisibles, como el VIH, deben notificarse al departamento de salud del estado. \"Consiento\" significa que est\u00e1 de acuerdo con algo. Al seleccionar el bot\u00f3n, acepta compartir su informaci\u00f3n personal con el equipo del estudio PROACT 1.     <\/div><\/div><fieldset id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Doy mi consentimiento para compartir mi informaci\u00f3n personal con el equipo del estudio PROACT 1.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_18'>\n\t\t\t<div class='gchoice gchoice_2_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Si'  id='choice_2_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_18_0' id='label_2_18_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_2_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Doy mi consentimiento para que se pongan en contacto conmigo para futuros estudios y para obtener informaci\u00f3n educativa.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_64'>\n\t\t\t<div class='gchoice gchoice_2_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Si'  id='choice_2_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_64_0' id='label_2_64_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_2_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_64_1' id='label_2_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n demogr\u00e1fica<\/h3><\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre completo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_2_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n de correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_2_2_container'>\n                                <span id='input_2_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_2_2' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n de correo electr\u00f3nico<\/label>\n                                    <input class='' type='email' name='input_2' id='input_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_2_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_2_2_2' class='gform-field-label gform-field-label--type-sub '>Confirmar direcci\u00f3n de correo electr\u00f3nico<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_2_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_2_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><fieldset id=\"field_2_4\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n de envio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_2_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_4_1_container' >\n                                        <label for='input_2_4_1' id='input_2_4_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n postal<\/label>\n                                        <input type='text' name='input_4.1' id='input_2_4_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_4_2_container' >\n                                        <label for='input_2_4_2' id='input_2_4_2_label' class='gform-field-label gform-field-label--type-sub '>L\u00ednea de direcci\u00f3n 2<\/label>\n                                        <input type='text' name='input_4.2' id='input_2_4_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_4_3_container' >\n                                    <label for='input_2_4_3' id='input_2_4_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                    <input type='text' name='input_4.3' id='input_2_4_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_4_4_container' >\n                                        <label for='input_2_4_4' id='input_2_4_4_label' class='gform-field-label gform-field-label--type-sub '>Estado<\/label>\n                                        <select name='input_4.4' id='input_2_4_4'     aria-required='true'   autocomplete=\"address-level1\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' selected='selected'>North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_4_5_container' >\n                                    <label for='input_2_4_5' id='input_2_4_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo postal<\/label>\n                                    <input type='text' name='input_4.5' id='input_2_4_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_2_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_2_93\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Edad:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_93'>\n\t\t\t<div class='gchoice gchoice_2_93_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='Menores de 18 a\u00f1os'  id='choice_2_93_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_0' id='label_2_93_0' class='gform-field-label gform-field-label--type-inline'>Menores de 18 a\u00f1os<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_93_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='18-29'  id='choice_2_93_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_1' id='label_2_93_1' class='gform-field-label gform-field-label--type-inline'>18-29<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_93_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='30-34'  id='choice_2_93_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_2' id='label_2_93_2' class='gform-field-label gform-field-label--type-inline'>30-34<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_93_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='35-44'  id='choice_2_93_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_3' id='label_2_93_3' class='gform-field-label gform-field-label--type-inline'>35-44<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_93_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='45-54'  id='choice_2_93_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_4' id='label_2_93_4' class='gform-field-label gform-field-label--type-inline'>45-54<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_93_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='55-64'  id='choice_2_93_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_5' id='label_2_93_5' class='gform-field-label gform-field-label--type-inline'>55-64<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_93_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='65-80'  id='choice_2_93_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_6' id='label_2_93_6' class='gform-field-label gform-field-label--type-inline'>65-80<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_93_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='80 a\u00f1os o m\u00e1s'  id='choice_2_93_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_93_7' id='label_2_93_7' class='gform-field-label gform-field-label--type-inline'>80 a\u00f1os o m\u00e1s<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sexo seg\u00fan los \u00f3rganos y funciones reproductores asignados al nacer:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_33'>\n\t\t\t<div class='gchoice gchoice_2_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Hombre'  id='choice_2_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_33_0' id='label_2_33_0' class='gform-field-label gform-field-label--type-inline'>Hombre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Female'  id='choice_2_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_33_1' id='label_2_33_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_92\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfCu\u00e1l es su origen racial\/\u00e9tnico? (Seleccione todas las opciones que procedan)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_92'>\n\t\t\t<div class='gchoice gchoice_2_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='White or Caucasian'  id='choice_2_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_0' id='label_2_92_0' class='gform-field-label gform-field-label--type-inline'>White or Caucasian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Black or African American'  id='choice_2_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_1' id='label_2_92_1' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_92_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Asian'  id='choice_2_92_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_2' id='label_2_92_2' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_92_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='American Indian or Alaska Native'  id='choice_2_92_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_3' id='label_2_92_3' class='gform-field-label gform-field-label--type-inline'>American Indian or Alaska Native<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_92_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Native Hawaiian or Other Pacific Islander'  id='choice_2_92_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_4' id='label_2_92_4' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian or Other Pacific Islander<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_92_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Latino or Hispanic'  id='choice_2_92_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_5' id='label_2_92_5' class='gform-field-label gform-field-label--type-inline'>Latino or Hispanic<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Cuestiones de salud<\/h3><div class='gsection_description' id='gfield_description_2_37'>Por favor, revise las siguientes condiciones y seleccione \"S\u00ed\" si tiene esta condici\u00f3n, y \"No\" si no la tiene.<\/div><\/div><fieldset id=\"field_2_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene antecedentes de diabetes de tipo 2 (el organismo no puede utilizar bien la insulina)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_56'>\n\t\t\t<div class='gchoice gchoice_2_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Si'  id='choice_2_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_56_0' id='label_2_56_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_2_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_56_1' id='label_2_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene antecedentes de trasplante de ri\u00f1\u00f3n o de otro \u00f3rgano (cirug\u00eda de sustituci\u00f3n de \u00f3rganos)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_51'>\n\t\t\t<div class='gchoice gchoice_2_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Si'  id='choice_2_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_51_0' id='label_2_51_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_2_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_51_1' id='label_2_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_95\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene antecedentes de enfermedad renal avanzada?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_95'>\n\t\t\t<div class='gchoice gchoice_2_95_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Si'  id='choice_2_95_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_95_0' id='label_2_95_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_95_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='No'  id='choice_2_95_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_95_1' id='label_2_95_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 actualmente en di\u00e1lisis?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_99'>\n\t\t\t<div class='gchoice gchoice_2_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Si'  id='choice_2_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_99_0' id='label_2_99_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='No'  id='choice_2_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_99_1' id='label_2_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfLe ha dicho su m\u00e9dico que necesitar\u00e1 di\u00e1lisis en los pr\u00f3ximos 18 meses?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_96'>\n\t\t\t<div class='gchoice gchoice_2_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Si'  id='choice_2_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_96_0' id='label_2_96_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_2_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_96_1' id='label_2_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_97\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 al cuidado de un nefr\u00f3logo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_97'>\n\t\t\t<div class='gchoice gchoice_2_97_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='Si'  id='choice_2_97_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_97_0' id='label_2_97_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_97_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='No'  id='choice_2_97_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_97_1' id='label_2_97_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_98\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfLe ha dicho su m\u00e9dico que necesitar\u00e1 un trasplante en los pr\u00f3ximos 2 a\u00f1os?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_98'>\n\t\t\t<div class='gchoice gchoice_2_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Si'  id='choice_2_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_98_0' id='label_2_98_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='No'  id='choice_2_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_98_1' id='label_2_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_90\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfQu\u00e9 distancia est\u00e1 dispuesto a recorrer para desplazarse a un centro de estudio? (Seleccione una opci\u00f3n): <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_90'>\n\t\t\t<div class='gchoice gchoice_2_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='Menos de 10 Millas'  id='choice_2_90_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_90_0' id='label_2_90_0' class='gform-field-label gform-field-label--type-inline'>Menos de 10 Millas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='10-20 Millas'  id='choice_2_90_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_90_1' id='label_2_90_1' class='gform-field-label gform-field-label--type-inline'>10-20 Millas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_90_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='20-30 Millas'  id='choice_2_90_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_90_2' id='label_2_90_2' class='gform-field-label gform-field-label--type-inline'>20-30 Millas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_90_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='M\u00e1s de 30 Millas'  id='choice_2_90_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_90_3' id='label_2_90_3' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de 30 Millas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_90_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='A otro Estado'  id='choice_2_90_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_90_4' id='label_2_90_4' class='gform-field-label gform-field-label--type-inline'>A otro Estado<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfNecesita ayuda con el transporte de ida y vuelta a la cl\u00ednica?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_91'>\n\t\t\t<div class='gchoice gchoice_2_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Si'  id='choice_2_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_91_0' id='label_2_91_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_2_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_91_1' id='label_2_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_101\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_2_101'>Identificaci\u00f3n \u00fanica&lt;br&gt;&lt;br&gt; &lt;br&gt; &lt;br&gt;<\/label><div class='ginput_container ginput_container_hidden'><input name='input_101' id='input_2_101' type='hidden' value=''  \/><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Gracias por rellenar la encuesta<\/h3><div class='gsection_description' id='gfield_description_2_10'>Gracias por dedicar su tiempo a completar nuestra encuesta de preselecci\u00f3n. Su inter\u00e9s es muy apreciado y nos ayuda a garantizar el \u00e9xito de nuestro estudio. Si tiene alguna pregunta o necesita m\u00e1s informaci\u00f3n, visite www.hopeforckd.com.\n<br>Saludos cordiales, Equipo de investigaci\u00f3n de PROACT 1  \n<\/div><\/div><div id=\"field_2_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Gracias por rellenar la encuesta<\/h3><div class='gsection_description' id='gfield_description_2_100'>Gracias por dedicar su tiempo a completar nuestra encuesta de preselecci\u00f3n. Su inter\u00e9s es muy apreciado y nos ayuda a garantizar el \u00e9xito de nuestro estudio. Si tiene alguna pregunta o necesita m\u00e1s informaci\u00f3n, visite www.hopeforckd.com.<br><br>Saludos cordiales, Equipo de investigaci\u00f3n de PROACT 1   \n<\/div><\/div><div id=\"field_2_94\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Gracias por rellenar la encuesta<\/h3><div class='gsection_description' id='gfield_description_2_94'>Gracias por dedicar su tiempo a completar nuestra encuesta de preselecci\u00f3n. Su inter\u00e9s es muy apreciado y nos ayuda a garantizar el \u00e9xito de nuestro estudio. Lamentablemente, no puede participar en el estudio PROACT 1, pero nos mantendremos en contacto con usted para informarle sobre la ERC e informarle sobre futuros estudios a medida que est\u00e9n disponibles. Si tiene alguna pregunta o necesita m\u00e1s informaci\u00f3n, visite www.hopeforckd.com. \nSaludos cordiales, Equipo de investigaci\u00f3n de PROACT 1\nGracias por ponerse en contacto con nosotros. En breve nos pondremos en contacto con usted.    \n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_105' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Pr\u00f3ximo'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-105' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_2_117\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_117' id='input_2_117' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='[channel]' \/><\/div><\/div><div id=\"field_2_118\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_118' id='input_2_118' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='[channeldrilldown1]' \/><\/div><\/div><div id=\"field_2_116\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_116' id='input_2_116' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='[channeldrilldown2]' \/><\/div><\/div><div id=\"field_2_115\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_115' id='input_2_115' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='[channeldrilldown3]' \/><\/div><\/div><div id=\"field_2_114\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_114' id='input_2_114' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='[landingpage]' \/><\/div><\/div><div id=\"field_2_113\" class=\"gfield 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