{"id":136,"date":"2020-06-14T06:26:24","date_gmt":"2020-06-14T06:26:24","guid":{"rendered":"http:\/\/targetedindividuals.ir\/?page_id=136"},"modified":"2022-09-14T23:36:40","modified_gmt":"2022-09-14T23:36:40","slug":"survey","status":"publish","type":"page","link":"https:\/\/targetedindividuals.ir\/index.php\/support\/survey\/","title":{"rendered":"Survey"},"content":{"rendered":"<div id=\"pl-136\"  class=\"panel-layout\" ><div id=\"pg-136-0\"  class=\"panel-grid panel-has-style\" ><div class=\"panel-row-style panel-row-style-for-136-0\" ><div id=\"pgc-136-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-136-0-0-0\" class=\"so-panel widget widget_sow-editor panel-first-child panel-last-child\" data-index=\"0\" ><div class=\"panel-widget-style panel-widget-style-for-136-0-0-0\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-editor so-widget-sow-editor-base\"\n\t\t\t\n\t\t>\n<div class=\"siteorigin-widget-tinymce textwidget\">\n\t<h2>Description of some of the fields<\/h2>\n<ul>\n<li><strong>- Started<\/strong>: which year did your attacks begin (the first time you noticed you are a target).<\/li>\n<li><strong>- Country<\/strong>: the country that you live in.<\/li>\n<\/ul>\n<p><strong>Dropdowns<\/strong>:<\/p>\n<ul>\n<li>- <strong>Reason<\/strong>, what is your best guess that you've become a target. If your reason is not in the list you have two options. First, you can choose \"Don't know\" or second, you can choose \"other reasons\". In the later case a text box will appear and you can write your reason.<\/li>\n<li>- If your choice is not in the list of other dropdowns, at the end of survey you see an option \"Anything else?\". By checking \"Yes\" next to this option a text box will appear and you can add your words.<\/li>\n<\/ul>\n<p><strong>Check boxes<\/strong>:<\/p>\n<ul>\n<li>- Multiple checks are possible.<\/li>\n<li>- Check any of the fields if they are applicable to your situation.<\/li>\n<li>- Check only if you are sure that these problem are caused by stalkers.<\/li>\n<li>- Don't check them if your problem is natural.<\/li>\n<\/ul>\n<p><strong>Text fields<\/strong>:<\/p>\n<ul>\n<li>- By some choices, there will appear a text field which enables you write your text. You may write anything you like. Please keep your text short.<\/li>\n<\/ul>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div><\/div><div id=\"pg-136-1\"  class=\"panel-grid panel-has-style\" ><div class=\"panel-row-style panel-row-style-for-136-1\" ><div id=\"pgc-136-1-0\"  class=\"panel-grid-cell\" ><div id=\"panel-136-1-0-0\" class=\"so-panel widget widget_text panel-first-child panel-last-child\" data-index=\"1\" ><div class=\"panel-widget-style panel-widget-style-for-136-1-0-0\" >\t\t\t<div class=\"textwidget\"><div class=\"caldera-grid\" id=\"caldera_form_1\" data-cf-ver=\"1.9.7\" data-cf-form-id=\"CF5f30eb7c95cca\"><div id=\"caldera_notices_1\" data-spinner=\"https:\/\/targetedindividuals.ir\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"1\" class=\"CF5f30eb7c95cca caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF5f30eb7c95cca_1\" data-form-id=\"CF5f30eb7c95cca\" aria-label=\"Survey\" data-target=\"#caldera_notices_1\" data-template=\"#cfajax_CF5f30eb7c95cca-tmpl\" data-cfajax=\"CF5f30eb7c95cca\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/targetedindividuals.ir\/cf-api\/CF5f30eb7c95cca\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF5f30eb7c95cca\" name=\"_cf_verify\" value=\"b447b9d835\"  data-nonce-time=\"1776479112\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/136\" \/><div id=\"cf2-CF5f30eb7c95cca_1\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF5f30eb7c95cca\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"1\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF5f30eb7c95cca\">\r\n<div class=\"hide\" style=\"display:none; overflow:hidden;height:0;width:0;\">\r\n<label>Company<\/label><input type=\"text\" name=\"company\" value=\"\" autocomplete=\"off\">\r\n<\/div><div id=\"CF5f30eb7c95cca_1-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-12  single\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_5658413_1\" data-field-id=\"fld_5658413_1\"><div data-field-wrapper=\"fld_5658413\" class=\"form-group\" id=\"fld_5658413_1-wrap\">\r\n\t<label id=\"fld_5658413Label\" for=\"fld_5658413_1\" class=\"control-label screen-reader-text sr-only\">mandatory text<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_5658413\" value=\"All the fields with a red star are mandatory, otherwise your form can not be submitted\" data-field=\"fld_5658413\" class=\"form-control\" id=\"fld_5658413_1\" rows=\"2\" default=\"All the fields with a red star are mandatory, otherwise your form can not be submitted\"    aria-labelledby=\"fld_5658413Label\" >All the fields with a red star are mandatory, otherwise your form can not be submitted<\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/span><\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-2\"  class=\"row \"><div  class=\"col-sm-2  first_col\"><div data-field-wrapper=\"fld_1616800\" class=\"form-group\" id=\"fld_1616800_1-wrap\">\r\n\t<label id=\"fld_1616800Label\" for=\"fld_1616800_1\" class=\"control-label\">Name<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_1616800\" class=\" form-control\" id=\"fld_1616800_1\" name=\"fld_1616800\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_1616800Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-1 \"><div data-field-wrapper=\"fld_6536389\" class=\"form-group\" id=\"fld_6536389_1-wrap\">\r\n\t<label id=\"fld_6536389Label\" for=\"fld_6536389_1\" class=\"control-label\">Age <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"number\" data-field=\"fld_6536389\" class=\" form-control\" id=\"fld_6536389_1\" name=\"fld_6536389\" value=\"\" data-type=\"number\" min=\"8\" max=\"95\" step=\"1\" data-parsley-type=\"number\" aria-required=\"true\"   aria-labelledby=\"fld_6536389Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_1480087\" class=\"form-group\" id=\"fld_1480087_1-wrap\">\r\n\t<label id=\"fld_1480087Label\" for=\"fld_1480087_1\" class=\"control-label\">Country <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_1480087\" value=\"opt246756499\" data-field=\"fld_1480087\" class=\"form-control\" id=\"fld_1480087_1\"  required=\"required\"  aria-labelledby=\"fld_1480087Label\" >\n\t\t\t\t\t\t\t<option value=\"Afghanistan\"  data-calc-value=\"Afghanistan\" >\n\t\t\t\t\t\tAfghanistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"\u00c5land Islands\"  data-calc-value=\"\u00c5land Islands\" >\n\t\t\t\t\t\t\u00c5land Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Albania\"  data-calc-value=\"Albania\" >\n\t\t\t\t\t\tAlbania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Algeria\"  data-calc-value=\"Algeria\" >\n\t\t\t\t\t\tAlgeria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"American Samoa\"  data-calc-value=\"American Samoa\" >\n\t\t\t\t\t\tAmerican Samoa\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Andorra\"  data-calc-value=\"Andorra\" >\n\t\t\t\t\t\tAndorra\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Angola\"  data-calc-value=\"Angola\" >\n\t\t\t\t\t\tAngola\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Anguilla\"  data-calc-value=\"Anguilla\" >\n\t\t\t\t\t\tAnguilla\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Antarctica\"  data-calc-value=\"Antarctica\" >\n\t\t\t\t\t\tAntarctica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Antigua and Barbuda\"  data-calc-value=\"Antigua and Barbuda\" >\n\t\t\t\t\t\tAntigua and Barbuda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Argentina\"  data-calc-value=\"Argentina\" >\n\t\t\t\t\t\tArgentina\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Armenia\"  data-calc-value=\"Armenia\" >\n\t\t\t\t\t\tArmenia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Aruba\"  data-calc-value=\"Aruba\" >\n\t\t\t\t\t\tAruba\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Australia\"  data-calc-value=\"Australia\" >\n\t\t\t\t\t\tAustralia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Austria\"  data-calc-value=\"Austria\" >\n\t\t\t\t\t\tAustria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Azerbaijan\"  data-calc-value=\"Azerbaijan\" >\n\t\t\t\t\t\tAzerbaijan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bahamas\"  data-calc-value=\"Bahamas\" >\n\t\t\t\t\t\tBahamas\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bahrain\"  data-calc-value=\"Bahrain\" >\n\t\t\t\t\t\tBahrain\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bangladesh\"  data-calc-value=\"Bangladesh\" >\n\t\t\t\t\t\tBangladesh\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Barbados\"  data-calc-value=\"Barbados\" >\n\t\t\t\t\t\tBarbados\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Belarus\"  data-calc-value=\"Belarus\" >\n\t\t\t\t\t\tBelarus\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Belgium\"  data-calc-value=\"Belgium\" >\n\t\t\t\t\t\tBelgium\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Belize\"  data-calc-value=\"Belize\" >\n\t\t\t\t\t\tBelize\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Benin\"  data-calc-value=\"Benin\" >\n\t\t\t\t\t\tBenin\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bermuda\"  data-calc-value=\"Bermuda\" >\n\t\t\t\t\t\tBermuda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bhutan\"  data-calc-value=\"Bhutan\" >\n\t\t\t\t\t\tBhutan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bolivia, Plurinational State of\"  data-calc-value=\"Bolivia, Plurinational State of\" >\n\t\t\t\t\t\tBolivia, Plurinational State of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bonaire, Sint Eustatius and Saba\"  data-calc-value=\"Bonaire, Sint Eustatius and Saba\" >\n\t\t\t\t\t\tBonaire, Sint Eustatius and Saba\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bosnia and Herzegovina\"  data-calc-value=\"Bosnia and Herzegovina\" >\n\t\t\t\t\t\tBosnia and Herzegovina\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Botswana\"  data-calc-value=\"Botswana\" >\n\t\t\t\t\t\tBotswana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bouvet Island\"  data-calc-value=\"Bouvet Island\" >\n\t\t\t\t\t\tBouvet Island\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Brazil\"  data-calc-value=\"Brazil\" >\n\t\t\t\t\t\tBrazil\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"British Indian Ocean Territory\"  data-calc-value=\"British Indian Ocean Territory\" >\n\t\t\t\t\t\tBritish Indian Ocean Territory\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Brunei Darussalam\"  data-calc-value=\"Brunei Darussalam\" >\n\t\t\t\t\t\tBrunei Darussalam\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Bulgaria\"  data-calc-value=\"Bulgaria\" >\n\t\t\t\t\t\tBulgaria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Burkina Faso\"  data-calc-value=\"Burkina Faso\" >\n\t\t\t\t\t\tBurkina Faso\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Burundi\"  data-calc-value=\"Burundi\" >\n\t\t\t\t\t\tBurundi\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cambodia\"  data-calc-value=\"Cambodia\" >\n\t\t\t\t\t\tCambodia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cameroon\"  data-calc-value=\"Cameroon\" >\n\t\t\t\t\t\tCameroon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Canada\"  data-calc-value=\"Canada\" >\n\t\t\t\t\t\tCanada\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cape Verde\"  data-calc-value=\"Cape Verde\" >\n\t\t\t\t\t\tCape Verde\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cayman Islands\"  data-calc-value=\"Cayman Islands\" >\n\t\t\t\t\t\tCayman Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Central African Republic\"  data-calc-value=\"Central African Republic\" >\n\t\t\t\t\t\tCentral African Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Chad\"  data-calc-value=\"Chad\" >\n\t\t\t\t\t\tChad\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Chile\"  data-calc-value=\"Chile\" >\n\t\t\t\t\t\tChile\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"China\"  data-calc-value=\"China\" >\n\t\t\t\t\t\tChina\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Christmas Island\"  data-calc-value=\"Christmas Island\" >\n\t\t\t\t\t\tChristmas Island\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cocos (Keeling) Islands\"  data-calc-value=\"Cocos (Keeling) Islands\" >\n\t\t\t\t\t\tCocos (Keeling) Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Colombia\"  data-calc-value=\"Colombia\" >\n\t\t\t\t\t\tColombia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Comoros\"  data-calc-value=\"Comoros\" >\n\t\t\t\t\t\tComoros\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Congo\"  data-calc-value=\"Congo\" >\n\t\t\t\t\t\tCongo\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Congo, the Democratic Republic of the\"  data-calc-value=\"Congo, the Democratic Republic of the\" >\n\t\t\t\t\t\tCongo, the Democratic Republic of the\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cook Islands\"  data-calc-value=\"Cook Islands\" >\n\t\t\t\t\t\tCook Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Costa Rica\"  data-calc-value=\"Costa Rica\" >\n\t\t\t\t\t\tCosta Rica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"C\u00f4te d&#039;Ivoire\"  data-calc-value=\"C\u00f4te d&#039;Ivoire\" >\n\t\t\t\t\t\tC\u00f4te d&#039;Ivoire\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Croatia\"  data-calc-value=\"Croatia\" >\n\t\t\t\t\t\tCroatia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cuba\"  data-calc-value=\"Cuba\" >\n\t\t\t\t\t\tCuba\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cura\u00e7ao\"  data-calc-value=\"Cura\u00e7ao\" >\n\t\t\t\t\t\tCura\u00e7ao\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Cyprus\"  data-calc-value=\"Cyprus\" >\n\t\t\t\t\t\tCyprus\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Czech Republic\"  data-calc-value=\"Czech Republic\" >\n\t\t\t\t\t\tCzech Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Denmark\"  data-calc-value=\"Denmark\" >\n\t\t\t\t\t\tDenmark\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Djibouti\"  data-calc-value=\"Djibouti\" >\n\t\t\t\t\t\tDjibouti\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Dominica\"  data-calc-value=\"Dominica\" >\n\t\t\t\t\t\tDominica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Dominican Republic\"  data-calc-value=\"Dominican Republic\" >\n\t\t\t\t\t\tDominican Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Ecuador\"  data-calc-value=\"Ecuador\" >\n\t\t\t\t\t\tEcuador\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Egypt\"  data-calc-value=\"Egypt\" >\n\t\t\t\t\t\tEgypt\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"El Salvador\"  data-calc-value=\"El Salvador\" >\n\t\t\t\t\t\tEl Salvador\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Equatorial Guinea\"  data-calc-value=\"Equatorial Guinea\" >\n\t\t\t\t\t\tEquatorial Guinea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Eritrea\"  data-calc-value=\"Eritrea\" >\n\t\t\t\t\t\tEritrea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Estonia\"  data-calc-value=\"Estonia\" >\n\t\t\t\t\t\tEstonia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Ethiopia\"  data-calc-value=\"Ethiopia\" >\n\t\t\t\t\t\tEthiopia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Falkland Islands (Malvinas)\"  data-calc-value=\"Falkland Islands (Malvinas)\" >\n\t\t\t\t\t\tFalkland Islands (Malvinas)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Faroe Islands\"  data-calc-value=\"Faroe Islands\" >\n\t\t\t\t\t\tFaroe Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Fiji\"  data-calc-value=\"Fiji\" >\n\t\t\t\t\t\tFiji\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Finland\"  data-calc-value=\"Finland\" >\n\t\t\t\t\t\tFinland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"France\"  data-calc-value=\"France\" >\n\t\t\t\t\t\tFrance\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"French Guiana\"  data-calc-value=\"French Guiana\" >\n\t\t\t\t\t\tFrench Guiana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"French Polynesia\"  data-calc-value=\"French Polynesia\" >\n\t\t\t\t\t\tFrench Polynesia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"French Southern Territories\"  data-calc-value=\"French Southern Territories\" >\n\t\t\t\t\t\tFrench Southern Territories\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Gabon\"  data-calc-value=\"Gabon\" >\n\t\t\t\t\t\tGabon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Gambia\"  data-calc-value=\"Gambia\" >\n\t\t\t\t\t\tGambia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Georgia\"  data-calc-value=\"Georgia\" >\n\t\t\t\t\t\tGeorgia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Germany\"  data-calc-value=\"Germany\" >\n\t\t\t\t\t\tGermany\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Ghana\"  data-calc-value=\"Ghana\" >\n\t\t\t\t\t\tGhana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Gibraltar\"  data-calc-value=\"Gibraltar\" >\n\t\t\t\t\t\tGibraltar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Greece\"  data-calc-value=\"Greece\" >\n\t\t\t\t\t\tGreece\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Greenland\"  data-calc-value=\"Greenland\" >\n\t\t\t\t\t\tGreenland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Grenada\"  data-calc-value=\"Grenada\" >\n\t\t\t\t\t\tGrenada\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Guadeloupe\"  data-calc-value=\"Guadeloupe\" >\n\t\t\t\t\t\tGuadeloupe\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Guam\"  data-calc-value=\"Guam\" >\n\t\t\t\t\t\tGuam\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Guatemala\"  data-calc-value=\"Guatemala\" >\n\t\t\t\t\t\tGuatemala\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Guernsey\"  data-calc-value=\"Guernsey\" >\n\t\t\t\t\t\tGuernsey\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Guinea\"  data-calc-value=\"Guinea\" >\n\t\t\t\t\t\tGuinea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Guinea-Bissau\"  data-calc-value=\"Guinea-Bissau\" >\n\t\t\t\t\t\tGuinea-Bissau\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Guyana\"  data-calc-value=\"Guyana\" >\n\t\t\t\t\t\tGuyana\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Haiti\"  data-calc-value=\"Haiti\" >\n\t\t\t\t\t\tHaiti\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Heard Island and McDonald Islands\"  data-calc-value=\"Heard Island and McDonald Islands\" >\n\t\t\t\t\t\tHeard Island and McDonald Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Holy See (Vatican City State)\"  data-calc-value=\"Holy See (Vatican City State)\" >\n\t\t\t\t\t\tHoly See (Vatican City State)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Honduras\"  data-calc-value=\"Honduras\" >\n\t\t\t\t\t\tHonduras\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Hong Kong\"  data-calc-value=\"Hong Kong\" >\n\t\t\t\t\t\tHong Kong\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Hungary\"  data-calc-value=\"Hungary\" >\n\t\t\t\t\t\tHungary\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Iceland\"  data-calc-value=\"Iceland\" >\n\t\t\t\t\t\tIceland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"India\"  data-calc-value=\"India\" >\n\t\t\t\t\t\tIndia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Indonesia\"  data-calc-value=\"Indonesia\" >\n\t\t\t\t\t\tIndonesia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Iran, Islamic Republic of\"  data-calc-value=\"Iran, Islamic Republic of\" >\n\t\t\t\t\t\tIran, Islamic Republic of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Iraq\"  data-calc-value=\"Iraq\" >\n\t\t\t\t\t\tIraq\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Ireland\"  data-calc-value=\"Ireland\" >\n\t\t\t\t\t\tIreland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Isle of Man\"  data-calc-value=\"Isle of Man\" >\n\t\t\t\t\t\tIsle of Man\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Israel\"  data-calc-value=\"Israel\" >\n\t\t\t\t\t\tIsrael\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Italy\"  data-calc-value=\"Italy\" >\n\t\t\t\t\t\tItaly\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Jamaica\"  data-calc-value=\"Jamaica\" >\n\t\t\t\t\t\tJamaica\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Japan\"  data-calc-value=\"Japan\" >\n\t\t\t\t\t\tJapan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Jersey\"  data-calc-value=\"Jersey\" >\n\t\t\t\t\t\tJersey\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Jordan\"  data-calc-value=\"Jordan\" >\n\t\t\t\t\t\tJordan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Kazakhstan\"  data-calc-value=\"Kazakhstan\" >\n\t\t\t\t\t\tKazakhstan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Kenya\"  data-calc-value=\"Kenya\" >\n\t\t\t\t\t\tKenya\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Kiribati\"  data-calc-value=\"Kiribati\" >\n\t\t\t\t\t\tKiribati\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Korea, Democratic People&#039;s Republic of\"  data-calc-value=\"Korea, Democratic People&#039;s Republic of\" >\n\t\t\t\t\t\tKorea, Democratic People&#039;s Republic of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Korea, Republic of\"  data-calc-value=\"Korea, Republic of\" >\n\t\t\t\t\t\tKorea, Republic of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Kuwait\"  data-calc-value=\"Kuwait\" >\n\t\t\t\t\t\tKuwait\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Kyrgyzstan\"  data-calc-value=\"Kyrgyzstan\" >\n\t\t\t\t\t\tKyrgyzstan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Lao People&#039;s Democratic Republic\"  data-calc-value=\"Lao People&#039;s Democratic Republic\" >\n\t\t\t\t\t\tLao People&#039;s Democratic Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Latvia\"  data-calc-value=\"Latvia\" >\n\t\t\t\t\t\tLatvia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Lebanon\"  data-calc-value=\"Lebanon\" >\n\t\t\t\t\t\tLebanon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Lesotho\"  data-calc-value=\"Lesotho\" >\n\t\t\t\t\t\tLesotho\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Liberia\"  data-calc-value=\"Liberia\" >\n\t\t\t\t\t\tLiberia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Libya\"  data-calc-value=\"Libya\" >\n\t\t\t\t\t\tLibya\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Liechtenstein\"  data-calc-value=\"Liechtenstein\" >\n\t\t\t\t\t\tLiechtenstein\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Lithuania\"  data-calc-value=\"Lithuania\" >\n\t\t\t\t\t\tLithuania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Luxembourg\"  data-calc-value=\"Luxembourg\" >\n\t\t\t\t\t\tLuxembourg\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Macao\"  data-calc-value=\"Macao\" >\n\t\t\t\t\t\tMacao\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Macedonia, the former Yugoslav Republic of\"  data-calc-value=\"Macedonia, the former Yugoslav Republic of\" >\n\t\t\t\t\t\tMacedonia, the former Yugoslav Republic of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Madagascar\"  data-calc-value=\"Madagascar\" >\n\t\t\t\t\t\tMadagascar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Malawi\"  data-calc-value=\"Malawi\" >\n\t\t\t\t\t\tMalawi\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Malaysia\"  data-calc-value=\"Malaysia\" >\n\t\t\t\t\t\tMalaysia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Maldives\"  data-calc-value=\"Maldives\" >\n\t\t\t\t\t\tMaldives\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Mali\"  data-calc-value=\"Mali\" >\n\t\t\t\t\t\tMali\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Malta\"  data-calc-value=\"Malta\" >\n\t\t\t\t\t\tMalta\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Marshall Islands\"  data-calc-value=\"Marshall Islands\" >\n\t\t\t\t\t\tMarshall Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Martinique\"  data-calc-value=\"Martinique\" >\n\t\t\t\t\t\tMartinique\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Mauritania\"  data-calc-value=\"Mauritania\" >\n\t\t\t\t\t\tMauritania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Mauritius\"  data-calc-value=\"Mauritius\" >\n\t\t\t\t\t\tMauritius\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Mayotte\"  data-calc-value=\"Mayotte\" >\n\t\t\t\t\t\tMayotte\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Mexico\"  data-calc-value=\"Mexico\" >\n\t\t\t\t\t\tMexico\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Micronesia, Federated States of\"  data-calc-value=\"Micronesia, Federated States of\" >\n\t\t\t\t\t\tMicronesia, Federated States of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Moldova, Republic of\"  data-calc-value=\"Moldova, Republic of\" >\n\t\t\t\t\t\tMoldova, Republic of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Monaco\"  data-calc-value=\"Monaco\" >\n\t\t\t\t\t\tMonaco\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Mongolia\"  data-calc-value=\"Mongolia\" >\n\t\t\t\t\t\tMongolia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Montenegro\"  data-calc-value=\"Montenegro\" >\n\t\t\t\t\t\tMontenegro\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Montserrat\"  data-calc-value=\"Montserrat\" >\n\t\t\t\t\t\tMontserrat\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Morocco\"  data-calc-value=\"Morocco\" >\n\t\t\t\t\t\tMorocco\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Mozambique\"  data-calc-value=\"Mozambique\" >\n\t\t\t\t\t\tMozambique\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Myanmar\"  data-calc-value=\"Myanmar\" >\n\t\t\t\t\t\tMyanmar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Namibia\"  data-calc-value=\"Namibia\" >\n\t\t\t\t\t\tNamibia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Nauru\"  data-calc-value=\"Nauru\" >\n\t\t\t\t\t\tNauru\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Nepal\"  data-calc-value=\"Nepal\" >\n\t\t\t\t\t\tNepal\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Netherlands\"  data-calc-value=\"Netherlands\" >\n\t\t\t\t\t\tNetherlands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"New Caledonia\"  data-calc-value=\"New Caledonia\" >\n\t\t\t\t\t\tNew Caledonia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"New Zealand\"  data-calc-value=\"New Zealand\" >\n\t\t\t\t\t\tNew Zealand\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Nicaragua\"  data-calc-value=\"Nicaragua\" >\n\t\t\t\t\t\tNicaragua\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Niger\"  data-calc-value=\"Niger\" >\n\t\t\t\t\t\tNiger\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Nigeria\"  data-calc-value=\"Nigeria\" >\n\t\t\t\t\t\tNigeria\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Niue\"  data-calc-value=\"Niue\" >\n\t\t\t\t\t\tNiue\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Norfolk Island\"  data-calc-value=\"Norfolk Island\" >\n\t\t\t\t\t\tNorfolk Island\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Northern Mariana Islands\"  data-calc-value=\"Northern Mariana Islands\" >\n\t\t\t\t\t\tNorthern Mariana Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Norway\"  data-calc-value=\"Norway\" >\n\t\t\t\t\t\tNorway\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Oman\"  data-calc-value=\"Oman\" >\n\t\t\t\t\t\tOman\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Pakistan\"  data-calc-value=\"Pakistan\" >\n\t\t\t\t\t\tPakistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Palau\"  data-calc-value=\"Palau\" >\n\t\t\t\t\t\tPalau\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Palestinian Territory, Occupied\"  data-calc-value=\"Palestinian Territory, Occupied\" >\n\t\t\t\t\t\tPalestinian Territory, Occupied\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Panama\"  data-calc-value=\"Panama\" >\n\t\t\t\t\t\tPanama\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Papua New Guinea\"  data-calc-value=\"Papua New Guinea\" >\n\t\t\t\t\t\tPapua New Guinea\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Paraguay\"  data-calc-value=\"Paraguay\" >\n\t\t\t\t\t\tParaguay\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Peru\"  data-calc-value=\"Peru\" >\n\t\t\t\t\t\tPeru\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Philippines\"  data-calc-value=\"Philippines\" >\n\t\t\t\t\t\tPhilippines\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Pitcairn\"  data-calc-value=\"Pitcairn\" >\n\t\t\t\t\t\tPitcairn\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Poland\"  data-calc-value=\"Poland\" >\n\t\t\t\t\t\tPoland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Portugal\"  data-calc-value=\"Portugal\" >\n\t\t\t\t\t\tPortugal\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Puerto Rico\"  data-calc-value=\"Puerto Rico\" >\n\t\t\t\t\t\tPuerto Rico\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Qatar\"  data-calc-value=\"Qatar\" >\n\t\t\t\t\t\tQatar\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"R\u00e9union\"  data-calc-value=\"R\u00e9union\" >\n\t\t\t\t\t\tR\u00e9union\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Romania\"  data-calc-value=\"Romania\" >\n\t\t\t\t\t\tRomania\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Russian Federation\"  data-calc-value=\"Russian Federation\" >\n\t\t\t\t\t\tRussian Federation\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Rwanda\"  data-calc-value=\"Rwanda\" >\n\t\t\t\t\t\tRwanda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Barth\u00e9lemy\"  data-calc-value=\"Saint Barth\u00e9lemy\" >\n\t\t\t\t\t\tSaint Barth\u00e9lemy\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Helena, Ascension and Tristan da Cunha\"  data-calc-value=\"Saint Helena, Ascension and Tristan da Cunha\" >\n\t\t\t\t\t\tSaint Helena, Ascension and Tristan da Cunha\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Kitts and Nevis\"  data-calc-value=\"Saint Kitts and Nevis\" >\n\t\t\t\t\t\tSaint Kitts and Nevis\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Lucia\"  data-calc-value=\"Saint Lucia\" >\n\t\t\t\t\t\tSaint Lucia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Martin (French part)\"  data-calc-value=\"Saint Martin (French part)\" >\n\t\t\t\t\t\tSaint Martin (French part)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Pierre and Miquelon\"  data-calc-value=\"Saint Pierre and Miquelon\" >\n\t\t\t\t\t\tSaint Pierre and Miquelon\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Vincent and the Grenadines\"  data-calc-value=\"Saint Vincent and the Grenadines\" >\n\t\t\t\t\t\tSaint Vincent and the Grenadines\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Samoa\"  data-calc-value=\"Samoa\" >\n\t\t\t\t\t\tSamoa\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"San Marino\"  data-calc-value=\"San Marino\" >\n\t\t\t\t\t\tSan Marino\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Sao Tome and Principe\"  data-calc-value=\"Sao Tome and Principe\" >\n\t\t\t\t\t\tSao Tome and Principe\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Saudi Arabia\"  data-calc-value=\"Saudi Arabia\" >\n\t\t\t\t\t\tSaudi Arabia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Senegal\"  data-calc-value=\"Senegal\" >\n\t\t\t\t\t\tSenegal\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Serbia\"  data-calc-value=\"Serbia\" >\n\t\t\t\t\t\tSerbia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Seychelles\"  data-calc-value=\"Seychelles\" >\n\t\t\t\t\t\tSeychelles\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Sierra Leone\"  data-calc-value=\"Sierra Leone\" >\n\t\t\t\t\t\tSierra Leone\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Singapore\"  data-calc-value=\"Singapore\" >\n\t\t\t\t\t\tSingapore\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Sint Maarten (Dutch part)\"  data-calc-value=\"Sint Maarten (Dutch part)\" >\n\t\t\t\t\t\tSint Maarten (Dutch part)\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Slovakia\"  data-calc-value=\"Slovakia\" >\n\t\t\t\t\t\tSlovakia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Slovenia\"  data-calc-value=\"Slovenia\" >\n\t\t\t\t\t\tSlovenia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Solomon Islands\"  data-calc-value=\"Solomon Islands\" >\n\t\t\t\t\t\tSolomon Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Somalia\"  data-calc-value=\"Somalia\" >\n\t\t\t\t\t\tSomalia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"South Africa\"  data-calc-value=\"South Africa\" >\n\t\t\t\t\t\tSouth Africa\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"South Georgia and the South Sandwich Islands\"  data-calc-value=\"South Georgia and the South Sandwich Islands\" >\n\t\t\t\t\t\tSouth Georgia and the South Sandwich Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"South Sudan\"  data-calc-value=\"South Sudan\" >\n\t\t\t\t\t\tSouth Sudan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Spain\"  data-calc-value=\"Spain\" >\n\t\t\t\t\t\tSpain\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Sri Lanka\"  data-calc-value=\"Sri Lanka\" >\n\t\t\t\t\t\tSri Lanka\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Sudan\"  data-calc-value=\"Sudan\" >\n\t\t\t\t\t\tSudan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Suriname\"  data-calc-value=\"Suriname\" >\n\t\t\t\t\t\tSuriname\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Svalbard and Jan Mayen\"  data-calc-value=\"Svalbard and Jan Mayen\" >\n\t\t\t\t\t\tSvalbard and Jan Mayen\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Swaziland\"  data-calc-value=\"Swaziland\" >\n\t\t\t\t\t\tSwaziland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Sweden\"  data-calc-value=\"Sweden\" >\n\t\t\t\t\t\tSweden\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Switzerland\"  data-calc-value=\"Switzerland\" >\n\t\t\t\t\t\tSwitzerland\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Syrian Arab Republic\"  data-calc-value=\"Syrian Arab Republic\" >\n\t\t\t\t\t\tSyrian Arab Republic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Taiwan, Province of China\"  data-calc-value=\"Taiwan, Province of China\" >\n\t\t\t\t\t\tTaiwan, Province of China\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Tajikistan\"  data-calc-value=\"Tajikistan\" >\n\t\t\t\t\t\tTajikistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Tanzania, United Republic of\"  data-calc-value=\"Tanzania, United Republic of\" >\n\t\t\t\t\t\tTanzania, United Republic of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Thailand\"  data-calc-value=\"Thailand\" >\n\t\t\t\t\t\tThailand\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Timor-Leste\"  data-calc-value=\"Timor-Leste\" >\n\t\t\t\t\t\tTimor-Leste\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Togo\"  data-calc-value=\"Togo\" >\n\t\t\t\t\t\tTogo\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Tokelau\"  data-calc-value=\"Tokelau\" >\n\t\t\t\t\t\tTokelau\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Tonga\"  data-calc-value=\"Tonga\" >\n\t\t\t\t\t\tTonga\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Trinidad and Tobago\"  data-calc-value=\"Trinidad and Tobago\" >\n\t\t\t\t\t\tTrinidad and Tobago\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Tunisia\"  data-calc-value=\"Tunisia\" >\n\t\t\t\t\t\tTunisia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Turkey\"  data-calc-value=\"Turkey\" >\n\t\t\t\t\t\tTurkey\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Turkmenistan\"  data-calc-value=\"Turkmenistan\" >\n\t\t\t\t\t\tTurkmenistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Turks and Caicos Islands\"  data-calc-value=\"Turks and Caicos Islands\" >\n\t\t\t\t\t\tTurks and Caicos Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Tuvalu\"  data-calc-value=\"Tuvalu\" >\n\t\t\t\t\t\tTuvalu\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Uganda\"  data-calc-value=\"Uganda\" >\n\t\t\t\t\t\tUganda\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Ukraine\"  data-calc-value=\"Ukraine\" >\n\t\t\t\t\t\tUkraine\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"United Arab Emirates\"  data-calc-value=\"United Arab Emirates\" >\n\t\t\t\t\t\tUnited Arab Emirates\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"United Kingdom\"  data-calc-value=\"United Kingdom\" >\n\t\t\t\t\t\tUnited Kingdom\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"United States\" selected=\"selected\" data-calc-value=\"United States\" >\n\t\t\t\t\t\tUnited States\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"United States Minor Outlying Islands\"  data-calc-value=\"United States Minor Outlying Islands\" >\n\t\t\t\t\t\tUnited States Minor Outlying Islands\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Uruguay\"  data-calc-value=\"Uruguay\" >\n\t\t\t\t\t\tUruguay\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Uzbekistan\"  data-calc-value=\"Uzbekistan\" >\n\t\t\t\t\t\tUzbekistan\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Vanuatu\"  data-calc-value=\"Vanuatu\" >\n\t\t\t\t\t\tVanuatu\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Venezuela, Bolivarian Republic of\"  data-calc-value=\"Venezuela, Bolivarian Republic of\" >\n\t\t\t\t\t\tVenezuela, Bolivarian Republic of\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Viet Nam\"  data-calc-value=\"Viet Nam\" >\n\t\t\t\t\t\tViet Nam\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, British\"  data-calc-value=\"Virgin Islands, British\" >\n\t\t\t\t\t\tVirgin Islands, British\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, U.S.\"  data-calc-value=\"Virgin Islands, U.S.\" >\n\t\t\t\t\t\tVirgin Islands, U.S.\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Wallis and Futuna\"  data-calc-value=\"Wallis and Futuna\" >\n\t\t\t\t\t\tWallis and Futuna\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Western Sahara\"  data-calc-value=\"Western Sahara\" >\n\t\t\t\t\t\tWestern Sahara\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Yemen\"  data-calc-value=\"Yemen\" >\n\t\t\t\t\t\tYemen\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Zambia\"  data-calc-value=\"Zambia\" >\n\t\t\t\t\t\tZambia\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwe\"  data-calc-value=\"Zimbabwe\" >\n\t\t\t\t\t\tZimbabwe\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_8451606\" class=\"form-group\" id=\"fld_8451606_1-wrap\">\r\n\t<label id=\"fld_8451606Label\" for=\"fld_8451606_1\" class=\"control-label\">State \/ Province <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_8451606\" class=\" form-control\" id=\"fld_8451606_1\" name=\"fld_8451606\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_8451606Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-1 \"><div data-field-wrapper=\"fld_5238615\" class=\"form-group\" id=\"fld_5238615_1-wrap\">\r\n\t<label id=\"fld_5238615Label\" for=\"fld_5238615_1\" class=\"control-label\">Started <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_5238615\" value=\"\" data-field=\"fld_5238615\" class=\"form-control\" id=\"fld_5238615_1\"  required=\"required\"  aria-labelledby=\"fld_5238615Label\" >\n\t\t<option value=\"\" disabled selected>Year began<\/option>\t\t\t\t\t<option value=\"1960\"  data-calc-value=\"1960\" >\n\t\t\t\t\t\t1960\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1961\"  data-calc-value=\"1961\" >\n\t\t\t\t\t\t1961\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1962\"  data-calc-value=\"1962\" >\n\t\t\t\t\t\t1962\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1963\"  data-calc-value=\"1963\" >\n\t\t\t\t\t\t1963\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1964\"  data-calc-value=\"1964\" >\n\t\t\t\t\t\t1964\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1965\"  data-calc-value=\"1965\" >\n\t\t\t\t\t\t1965\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1966\"  data-calc-value=\"1966\" >\n\t\t\t\t\t\t1966\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1967\"  data-calc-value=\"1967\" >\n\t\t\t\t\t\t1967\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1968\"  data-calc-value=\"1968\" >\n\t\t\t\t\t\t1968\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1969\"  data-calc-value=\"1969\" >\n\t\t\t\t\t\t1969\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1970\"  data-calc-value=\"1970\" >\n\t\t\t\t\t\t1970\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1971\"  data-calc-value=\"1971\" >\n\t\t\t\t\t\t1971\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1972\"  data-calc-value=\"1972\" >\n\t\t\t\t\t\t1972\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1973\"  data-calc-value=\"1973\" >\n\t\t\t\t\t\t1973\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1974\"  data-calc-value=\"1974\" >\n\t\t\t\t\t\t1974\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1975\"  data-calc-value=\"1975\" >\n\t\t\t\t\t\t1975\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1976\"  data-calc-value=\"1976\" >\n\t\t\t\t\t\t1976\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1977\"  data-calc-value=\"1977\" >\n\t\t\t\t\t\t1977\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1978\"  data-calc-value=\"1978\" >\n\t\t\t\t\t\t1978\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1979\"  data-calc-value=\"1979\" >\n\t\t\t\t\t\t1979\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1980\"  data-calc-value=\"1980\" >\n\t\t\t\t\t\t1980\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1981\"  data-calc-value=\"1981\" >\n\t\t\t\t\t\t1981\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1982\"  data-calc-value=\"1982\" >\n\t\t\t\t\t\t1982\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1983\"  data-calc-value=\"1983\" >\n\t\t\t\t\t\t1983\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1984\"  data-calc-value=\"1984\" >\n\t\t\t\t\t\t1984\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1985\"  data-calc-value=\"1985\" >\n\t\t\t\t\t\t1985\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1986\"  data-calc-value=\"1986\" >\n\t\t\t\t\t\t1986\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1987\"  data-calc-value=\"1987\" >\n\t\t\t\t\t\t1987\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1988\"  data-calc-value=\"1988\" >\n\t\t\t\t\t\t1988\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1989\"  data-calc-value=\"1989\" >\n\t\t\t\t\t\t1989\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1990\"  data-calc-value=\"1990\" >\n\t\t\t\t\t\t1990\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1991\"  data-calc-value=\"1991\" >\n\t\t\t\t\t\t1991\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1992\"  data-calc-value=\"1992\" >\n\t\t\t\t\t\t1992\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1993\"  data-calc-value=\"1993\" >\n\t\t\t\t\t\t1993\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1994\"  data-calc-value=\"1994\" >\n\t\t\t\t\t\t1994\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1995\"  data-calc-value=\"1995\" >\n\t\t\t\t\t\t1995\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1996\"  data-calc-value=\"1996\" >\n\t\t\t\t\t\t1996\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1997\"  data-calc-value=\"1997\" >\n\t\t\t\t\t\t1997\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1998\"  data-calc-value=\"1998\" >\n\t\t\t\t\t\t1998\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"1999\"  data-calc-value=\"1999\" >\n\t\t\t\t\t\t1999\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2000\"  data-calc-value=\"2000\" >\n\t\t\t\t\t\t2000\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2001\"  data-calc-value=\"2001\" >\n\t\t\t\t\t\t2001\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2002\"  data-calc-value=\"2002\" >\n\t\t\t\t\t\t2002\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2003\"  data-calc-value=\"2003\" >\n\t\t\t\t\t\t2003\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2004\"  data-calc-value=\"2004\" >\n\t\t\t\t\t\t2004\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2005\"  data-calc-value=\"2005\" >\n\t\t\t\t\t\t2005\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2006\"  data-calc-value=\"2006\" >\n\t\t\t\t\t\t2006\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2007\"  data-calc-value=\"2007\" >\n\t\t\t\t\t\t2007\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2008\"  data-calc-value=\"2008\" >\n\t\t\t\t\t\t2008\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2009\"  data-calc-value=\"2009\" >\n\t\t\t\t\t\t2009\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2010\"  data-calc-value=\"2010\" >\n\t\t\t\t\t\t2010\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2011\"  data-calc-value=\"2011\" >\n\t\t\t\t\t\t2011\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2012\"  data-calc-value=\"2012\" >\n\t\t\t\t\t\t2012\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2013\"  data-calc-value=\"2013\" >\n\t\t\t\t\t\t2013\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2014\"  data-calc-value=\"2014\" >\n\t\t\t\t\t\t2014\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2015\"  data-calc-value=\"2015\" >\n\t\t\t\t\t\t2015\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2016\"  data-calc-value=\"2016\" >\n\t\t\t\t\t\t2016\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2017\"  data-calc-value=\"2017\" >\n\t\t\t\t\t\t2017\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2018\"  data-calc-value=\"2018\" >\n\t\t\t\t\t\t2018\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2019\"  data-calc-value=\"2019\" >\n\t\t\t\t\t\t2019\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2020\"  data-calc-value=\"2020\" >\n\t\t\t\t\t\t2020\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2021\"  data-calc-value=\"2021\" >\n\t\t\t\t\t\t2021\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"2022\"  data-calc-value=\"2022\" >\n\t\t\t\t\t\t2022\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_154462\" class=\"form-group\" id=\"fld_154462_1-wrap\">\r\n\t<label id=\"fld_154462Label\" for=\"fld_154462_1\" class=\"control-label\">Gender <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_154462\" value=\"opt942025\" data-field=\"fld_154462\" class=\"form-control\" id=\"fld_154462_1\"  required=\"required\"  aria-labelledby=\"fld_154462Label\" >\n\t\t<option value=\"\" disabled >Your Gender<\/option>\t\t\t\t\t<option value=\"Female\"  data-calc-value=\"Female\" >\n\t\t\t\t\t\tFemale\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Intersex\"  data-calc-value=\"Intersex\" >\n\t\t\t\t\t\tIntersex\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Male\" selected=\"selected\" data-calc-value=\"Male\" >\n\t\t\t\t\t\tMale\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Transsexual\"  data-calc-value=\"Transsexual\" >\n\t\t\t\t\t\tTranssexual\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Other\"  data-calc-value=\"Other\" >\n\t\t\t\t\t\tOther\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2  last_col\"><div data-field-wrapper=\"fld_9760123\" class=\"form-group\" id=\"fld_9760123_1-wrap\">\r\n\t<label id=\"fld_9760123Label\" for=\"fld_9760123_1\" class=\"control-label\">Reason <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_9760123\" value=\"opt7104110\" data-field=\"fld_9760123\" class=\"form-control\" id=\"fld_9760123_1\"  required=\"required\"  aria-labelledby=\"fld_9760123Label\" >\n\t\t<option value=\"\" disabled >Why you've become TI <\/option>\t\t\t\t\t<option value=\"Color\"  data-calc-value=\"Color\" >\n\t\t\t\t\t\tColor\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Hatred\"  data-calc-value=\"Hatred\" >\n\t\t\t\t\t\tHatred\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Ideological\"  data-calc-value=\"Ideological\" >\n\t\t\t\t\t\tIdeological\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Jealousy\"  data-calc-value=\"Jealousy\" >\n\t\t\t\t\t\tJealousy\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Nationality\"  data-calc-value=\"Nationality\" >\n\t\t\t\t\t\tNationality\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Outspoken\"  data-calc-value=\"Outspoken\" >\n\t\t\t\t\t\tOutspoken\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Revenge\" selected=\"selected\" data-calc-value=\"Revenge\" >\n\t\t\t\t\t\tRevenge\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Religious\"  data-calc-value=\"Religious\" >\n\t\t\t\t\t\tReligious\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Silencing\"  data-calc-value=\"Silencing\" >\n\t\t\t\t\t\tSilencing\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Sexual Orientation\"  data-calc-value=\"Sexual Orientation\" >\n\t\t\t\t\t\tSexual Orientation\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Other Reason\"  data-calc-value=\"Other Reason\" >\n\t\t\t\t\t\tOther Reason\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Don&#039;t Know\"  data-calc-value=\"Don&#039;t Know\" >\n\t\t\t\t\t\tDon&#039;t Know\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-3\"  class=\"row \"><div  class=\"col-sm-2  first_col\"><div data-field-wrapper=\"fld_3829875\" class=\"form-group\" id=\"fld_3829875_1-wrap\">\r\n\t<label id=\"fld_3829875Label\" for=\"fld_3829875_1\" class=\"control-label\">Education<\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_3829875\" value=\"opt1604602\" data-field=\"fld_3829875\" class=\"form-control\" id=\"fld_3829875_1\"    aria-labelledby=\"fld_3829875Label\" >\n\t\t<option value=\"\" disabled >Your Education<\/option>\t\t\t\t\t<option value=\"Bachelor\"  data-calc-value=\"Bachelor\" >\n\t\t\t\t\t\tBachelor\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Basic\"  data-calc-value=\"Basic\" >\n\t\t\t\t\t\tBasic\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"High School\" selected=\"selected\" data-calc-value=\"High School\" >\n\t\t\t\t\t\tHigh School\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Master\"  data-calc-value=\"Master\" >\n\t\t\t\t\t\tMaster\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"PhD\"  data-calc-value=\"PhD\" >\n\t\t\t\t\t\tPhD\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Other\"  data-calc-value=\"Other\" >\n\t\t\t\t\t\tOther\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_7835994\" class=\"form-group\" id=\"fld_7835994_1-wrap\">\r\n\t<label id=\"fld_7835994Label\" for=\"fld_7835994_1\" class=\"control-label\">Religion<\/label>\r\n\t<div class=\"\">\r\n\t\t<select name=\"fld_7835994\" value=\"opt3314846\" data-field=\"fld_7835994\" class=\"form-control\" id=\"fld_7835994_1\"    aria-labelledby=\"fld_7835994Label\" >\n\t\t<option value=\"\" disabled >Your Religion<\/option>\t\t\t\t\t<option value=\"African traditional\"  data-calc-value=\"African traditional\" >\n\t\t\t\t\t\tAfrican traditional\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Buddhism\"  data-calc-value=\"Buddhism\" >\n\t\t\t\t\t\tBuddhism\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Chinese traditional\"  data-calc-value=\"Chinese traditional\" >\n\t\t\t\t\t\tChinese traditional\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Christianity\" selected=\"selected\" data-calc-value=\"Christianity\" >\n\t\t\t\t\t\tChristianity\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Folk religion\"  data-calc-value=\"Folk religion\" >\n\t\t\t\t\t\tFolk religion\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Hinduism\"  data-calc-value=\"Hinduism\" >\n\t\t\t\t\t\tHinduism\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Islam\"  data-calc-value=\"Islam\" >\n\t\t\t\t\t\tIslam\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Judaism\"  data-calc-value=\"Judaism\" >\n\t\t\t\t\t\tJudaism\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Nonreligious\"  data-calc-value=\"Nonreligious\" >\n\t\t\t\t\t\tNonreligious\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Primal-indigenous\"  data-calc-value=\"Primal-indigenous\" >\n\t\t\t\t\t\tPrimal-indigenous\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Zoroastrianism\"  data-calc-value=\"Zoroastrianism\" >\n\t\t\t\t\t\tZoroastrianism\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t<option value=\"Other\"  data-calc-value=\"Other\" >\n\t\t\t\t\t\tOther\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_1231649\" class=\"form-group\" id=\"fld_1231649_1-wrap\">\r\n\t<label id=\"fld_1231649Label\" for=\"fld_1231649_1\" class=\"control-label\">Occupation<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"text\" data-field=\"fld_1231649\" class=\" form-control\" id=\"fld_1231649_1\" name=\"fld_1231649\" value=\"\" data-type=\"text\"   aria-labelledby=\"fld_1231649Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_4717624\" class=\"form-group\" id=\"fld_4717624_1-wrap\">\r\n\t<label id=\"fld_4717624Label\" for=\"fld_4717624_1\" class=\"control-label\">Phone<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"tel\" data-field=\"fld_4717624\" class=\" form-control\" id=\"fld_4717624_1\" name=\"fld_4717624\" value=\"\" data-type=\"phone_better\"   aria-labelledby=\"fld_4717624Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-4  last_col\"><div data-field-wrapper=\"fld_343303\" class=\"form-group\" id=\"fld_343303_1-wrap\">\r\n\t<label id=\"fld_343303Label\" for=\"fld_343303_1\" class=\"control-label\">Your email address <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_343303\" class=\" form-control\" id=\"fld_343303_1\" name=\"fld_343303\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_343303Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-4\"  class=\"row \"><div  class=\"col-sm-12  single\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_4029722_1\" data-field-id=\"fld_4029722_1\"><\/span><\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-5\"  class=\"row \"><div  class=\"col-sm-12  single\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_7226278_1\" data-field-id=\"fld_7226278_1\"><div data-field-wrapper=\"fld_7226278\" class=\"form-group\" id=\"fld_7226278_1-wrap\">\r\n\t<label id=\"fld_7226278Label\" for=\"fld_7226278_1\" class=\"control-label\">List of problems you may have<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7226278\" value=\"Below is the list of problems I have. If you need to add something that is not in the list please go to contact and send your subject via email. \" data-field=\"fld_7226278\" class=\"form-control\" id=\"fld_7226278_1\" rows=\"1\" default=\"Below is the list of problems I have. If you need to add something that is not in the list please go to contact and send your subject via email. \"    aria-labelledby=\"fld_7226278Label\" >Below is the list of problems I have. If you need to add something that is not in the list please go to contact and send your subject via email. <\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/span><\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-6\"  class=\"row \"><div  class=\"col-sm-2  first_col\"><div data-field-wrapper=\"fld_4635733\" class=\"form-group\" id=\"fld_4635733_1-wrap\">\r\n\t<label id=\"fld_4635733Label\" for=\"fld_4635733_1\" class=\"control-label\">Pain<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt1194152\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Belly\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt1194152\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt1194152]\"\n                                value=\"Belly\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Belly\"\n                            >\n                    Belly                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt172378\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Bone\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt172378\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt172378]\"\n                                value=\"Bone\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Bone\"\n                            >\n                    Bone                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt1820424\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Ear\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt1820424\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt1820424]\"\n                                value=\"Ear\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Ear\"\n                            >\n                    Ear                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt1254347\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Eye\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt1254347\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt1254347]\"\n                                value=\"Eye\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Eye\"\n                            >\n                    Eye                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt2468062\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Headache\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt2468062\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt2468062]\"\n                                value=\"Headache\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Headache\"\n                            >\n                    Headache                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt3306383\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Heart\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt3306383\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt3306383]\"\n                                value=\"Heart\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Heart\"\n                            >\n                    Heart                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt5159066\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Muscle\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt5159066\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt5159066]\"\n                                value=\"Muscle\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Muscle\"\n                            >\n                    Muscle                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4635733_1_opt5839042\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Tooth\"\n                                data-field=\"fld_4635733\"\n                                id=\"fld_4635733_1_opt5839042\"\n                                class=\"fld_4635733_1\"\n                                name=\"fld_4635733[opt5839042]\"\n                                value=\"Tooth\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4635733_1\"\n                                                                data-calc-value=\"Tooth\"\n                            >\n                    Tooth                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_2000762\" class=\"form-group\" id=\"fld_2000762_1-wrap\">\r\n\t<label id=\"fld_2000762Label\" for=\"fld_2000762_1\" class=\"control-label\">Burn sensations<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2000762_1_opt200941\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Eye\"\n                                data-field=\"fld_2000762\"\n                                id=\"fld_2000762_1_opt200941\"\n                                class=\"fld_2000762_1\"\n                                name=\"fld_2000762[opt200941]\"\n                                value=\"  Eye\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2000762_1\"\n                                                                data-calc-value=\"  Eye\"\n                            >\n                      Eye                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2000762_1_opt1692775\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Foot\"\n                                data-field=\"fld_2000762\"\n                                id=\"fld_2000762_1_opt1692775\"\n                                class=\"fld_2000762_1\"\n                                name=\"fld_2000762[opt1692775]\"\n                                value=\"  Foot\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2000762_1\"\n                                                                data-calc-value=\"  Foot\"\n                            >\n                      Foot                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2000762_1_opt2516776\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Mouth\"\n                                data-field=\"fld_2000762\"\n                                id=\"fld_2000762_1_opt2516776\"\n                                class=\"fld_2000762_1\"\n                                name=\"fld_2000762[opt2516776]\"\n                                value=\"  Mouth\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2000762_1\"\n                                                                data-calc-value=\"  Mouth\"\n                            >\n                      Mouth                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2000762_1_opt3955532\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Nose\"\n                                data-field=\"fld_2000762\"\n                                id=\"fld_2000762_1_opt3955532\"\n                                class=\"fld_2000762_1\"\n                                name=\"fld_2000762[opt3955532]\"\n                                value=\"  Nose\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2000762_1\"\n                                                                data-calc-value=\"  Nose\"\n                            >\n                      Nose                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2000762_1_opt4928707\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Skin\"\n                                data-field=\"fld_2000762\"\n                                id=\"fld_2000762_1_opt4928707\"\n                                class=\"fld_2000762_1\"\n                                name=\"fld_2000762[opt4928707]\"\n                                value=\"  Skin\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2000762_1\"\n                                                                data-calc-value=\"  Skin\"\n                            >\n                      Skin                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2000762_1_opt5699066\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Tongue\"\n                                data-field=\"fld_2000762\"\n                                id=\"fld_2000762_1_opt5699066\"\n                                class=\"fld_2000762_1\"\n                                name=\"fld_2000762[opt5699066]\"\n                                value=\"  Tongue\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2000762_1\"\n                                                                data-calc-value=\"  Tongue\"\n                            >\n                      Tongue                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_4300332\" class=\"form-group\" id=\"fld_4300332_1-wrap\">\r\n\t<label id=\"fld_4300332Label\" for=\"fld_4300332_1\" class=\"control-label\">Untimely functions<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt27983\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Coughing\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt27983\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt27983]\"\n                                value=\"Coughing\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"Coughing\"\n                            >\n                    Coughing                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt1063787\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Crying\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt1063787\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt1063787]\"\n                                value=\"  Crying\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Crying\"\n                            >\n                      Crying                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt2120412\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Defecating\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt2120412\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt2120412]\"\n                                value=\"  Defecating\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Defecating\"\n                            >\n                      Defecating                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt3489500\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Farting\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt3489500\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt3489500]\"\n                                value=\"  Farting\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Farting\"\n                            >\n                      Farting                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt4237964\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Itching\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt4237964\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt4237964]\"\n                                value=\"  Itching\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Itching\"\n                            >\n                      Itching                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt6230684\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Sneezing\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt6230684\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt6230684]\"\n                                value=\"  Sneezing\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Sneezing\"\n                            >\n                      Sneezing                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt6658400\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Snorting\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt6658400\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt6658400]\"\n                                value=\"  Snorting\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Snorting\"\n                            >\n                      Snorting                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt8126549\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Sniveling\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt8126549\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt8126549]\"\n                                value=\"  Sniveling\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Sniveling\"\n                            >\n                      Sniveling                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt9137209\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Sweating\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt9137209\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt9137209]\"\n                                value=\"  Sweating\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Sweating\"\n                            >\n                      Sweating                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_4300332_1_opt9762795\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Urination\"\n                                data-field=\"fld_4300332\"\n                                id=\"fld_4300332_1_opt9762795\"\n                                class=\"fld_4300332_1\"\n                                name=\"fld_4300332[opt9762795]\"\n                                value=\"  Urination\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_4300332_1\"\n                                                                data-calc-value=\"  Urination\"\n                            >\n                      Urination                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_2143819\" class=\"form-group\" id=\"fld_2143819_1-wrap\">\r\n\t<label id=\"fld_2143819Label\" for=\"fld_2143819_1\" class=\"control-label\">Mental sensations<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt1709501\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Anger\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt1709501\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt1709501]\"\n                                value=\"Anger\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"Anger\"\n                            >\n                    Anger                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt1348768\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Forgetfulness\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt1348768\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt1348768]\"\n                                value=\"Forgetfulness\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"Forgetfulness\"\n                            >\n                    Forgetfulness                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt1480800\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Joyfulness\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt1480800\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt1480800]\"\n                                value=\"  Joyfulness\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"  Joyfulness\"\n                            >\n                      Joyfulness                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt2580679\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Sadness\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt2580679\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt2580679]\"\n                                value=\"  Sadness\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"  Sadness\"\n                            >\n                      Sadness                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt1596737\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Sexual stimulation\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt1596737\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt1596737]\"\n                                value=\"Sexual stimulation\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"Sexual stimulation\"\n                            >\n                    Sexual stimulation                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt3250174\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Skepticism\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt3250174\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt3250174]\"\n                                value=\"  Skepticism\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"  Skepticism\"\n                            >\n                      Skepticism                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt4281590\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Sudden tiredness\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt4281590\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt4281590]\"\n                                value=\"  Sudden tiredness\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"  Sudden tiredness\"\n                            >\n                      Sudden tiredness                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2143819_1_opt787144\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Uncertainty\"\n                                data-field=\"fld_2143819\"\n                                id=\"fld_2143819_1_opt787144\"\n                                class=\"fld_2143819_1\"\n                                name=\"fld_2143819[opt787144]\"\n                                value=\"  Uncertainty\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2143819_1\"\n                                                                data-calc-value=\"  Uncertainty\"\n                            >\n                      Uncertainty                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-4  last_col\"><div data-field-wrapper=\"fld_7001999\" class=\"form-group\" id=\"fld_7001999_1-wrap\">\r\n\t<label id=\"fld_7001999Label\" for=\"fld_7001999_1\" class=\"control-label\">Other problems<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt8183227\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Blood flow prevention: fingers, hands\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt8183227\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt8183227]\"\n                                value=\"Blood flow prevention: fingers, hands\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"Blood flow prevention: fingers, hands\"\n                            >\n                    Blood flow prevention: fingers, hands                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt849939\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Defocusing eyes\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt849939\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt849939]\"\n                                value=\"Defocusing eyes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"Defocusing eyes\"\n                            >\n                    Defocusing eyes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt1940066\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Functional arrest (speak, muscle)\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt1940066\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt1940066]\"\n                                value=\"Functional arrest (speak, muscle)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"Functional arrest (speak, muscle)\"\n                            >\n                    Functional arrest (speak, muscle)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt1833065\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Increase\/decrease heart rate\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt1833065\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt1833065]\"\n                                value=\"  Increase\/decrease heart rate\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"  Increase\/decrease heart rate\"\n                            >\n                      Increase\/decrease heart rate                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt2116795\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Increase\/decrease blood pressure\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt2116795\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt2116795]\"\n                                value=\"  Increase\/decrease blood pressure\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"  Increase\/decrease blood pressure\"\n                            >\n                      Increase\/decrease blood pressure                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt9005410\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Lose of balance\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt9005410\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt9005410]\"\n                                value=\"Lose of balance\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"Lose of balance\"\n                            >\n                    Lose of balance                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt3962333\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Lung malfunction (breath shortage)\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt3962333\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt3962333]\"\n                                value=\"  Lung malfunction (breath shortage)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"  Lung malfunction (breath shortage)\"\n                            >\n                      Lung malfunction (breath shortage)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt4656813\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Muscle stimulation\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt4656813\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt4656813]\"\n                                value=\"  Muscle stimulation\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"  Muscle stimulation\"\n                            >\n                      Muscle stimulation                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt6912708\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Pressure on chest, skin, bone\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt6912708\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt6912708]\"\n                                value=\"  Pressure on chest, skin, bone\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"  Pressure on chest, skin, bone\"\n                            >\n                      Pressure on chest, skin, bone                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt11325029\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Strange movements under skin\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt11325029\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt11325029]\"\n                                value=\"  Strange movements under skin\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"  Strange movements under skin\"\n                            >\n                      Strange movements under skin                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt10459663\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"  Stoppage of throat\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt10459663\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt10459663]\"\n                                value=\"  Stoppage of throat\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"  Stoppage of throat\"\n                            >\n                      Stoppage of throat                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_7001999_1_opt6209186\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Tinnitus (noise in ear)\"\n                                data-field=\"fld_7001999\"\n                                id=\"fld_7001999_1_opt6209186\"\n                                class=\"fld_7001999_1\"\n                                name=\"fld_7001999[opt6209186]\"\n                                value=\"Tinnitus (noise in ear)\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_7001999_1\"\n                                                                data-calc-value=\"Tinnitus (noise in ear)\"\n                            >\n                    Tinnitus (noise in ear)                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-7\"  class=\"row \"><div  class=\"col-sm-12  single\"><hr id=\"fld_6671751_1\" class=\"\" style=\"width: 100%\" \/><\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-8\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_3374695\" class=\"form-group\" id=\"fld_3374695_1-wrap\">\r\n\t<label id=\"fld_3374695Label\" for=\"fld_3374695_1\" class=\"control-label\">Damages<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1154088\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Car\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1154088\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1154088]\"\n                                value=\"Car\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Car\"\n                            >\n                    Car                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1243556\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Divorce or break up\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1243556\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1243556]\"\n                                value=\"Divorce or break up\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Divorce or break up\"\n                            >\n                    Divorce or break up                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1402465\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Forced detention\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1402465\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1402465]\"\n                                value=\"Forced detention\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Forced detention\"\n                            >\n                    Forced detention                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1715765\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"House\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1715765\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1715765]\"\n                                value=\"House\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"House\"\n                            >\n                    House                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1355977\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Job loss\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1355977\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1355977]\"\n                                value=\"Job loss\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Job loss\"\n                            >\n                    Job loss                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1897591\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Mental institutions\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1897591\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1897591]\"\n                                value=\"Mental institutions\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Mental institutions\"\n                            >\n                    Mental institutions                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1428859\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Pet\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1428859\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1428859]\"\n                                value=\"Pet\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Pet\"\n                            >\n                    Pet                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1607140\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Relationship\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1607140\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1607140]\"\n                                value=\"Relationship\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Relationship\"\n                            >\n                    Relationship                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_3374695_1_opt1520724\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Theft\"\n                                data-field=\"fld_3374695\"\n                                id=\"fld_3374695_1_opt1520724\"\n                                class=\"fld_3374695_1\"\n                                name=\"fld_3374695[opt1520724]\"\n                                value=\"Theft\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_3374695_1\"\n                                                                data-calc-value=\"Theft\"\n                            >\n                    Theft                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_5624415\" class=\"form-group\" id=\"fld_5624415_1-wrap\">\r\n\t<label id=\"fld_5624415Label\" for=\"fld_5624415_1\" class=\"control-label\">Assistance requested<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1113856\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Ambulance\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1113856\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1113856]\"\n                                value=\"Ambulance\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Ambulance\"\n                            >\n                    Ambulance                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1158316\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Fire fighter\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1158316\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1158316]\"\n                                value=\"Fire fighter\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Fire fighter\"\n                            >\n                    Fire fighter                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1817909\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Family\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1817909\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1817909]\"\n                                value=\"Family\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Family\"\n                            >\n                    Family                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1968762\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Friend\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1968762\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1968762]\"\n                                value=\"Friend\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Friend\"\n                            >\n                    Friend                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1389019\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Medical institutions\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1389019\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1389019]\"\n                                value=\"Medical institutions\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Medical institutions\"\n                            >\n                    Medical institutions                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1244649\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Social workers\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1244649\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1244649]\"\n                                value=\"Social workers\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Social workers\"\n                            >\n                    Social workers                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1087788\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Police\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1087788\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1087788]\"\n                                value=\"Police\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Police\"\n                            >\n                    Police                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1572663\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Psychiatrist\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1572663\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1572663]\"\n                                value=\"Psychiatrist\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Psychiatrist\"\n                            >\n                    Psychiatrist                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_5624415_1_opt1864046\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Psychologist\"\n                                data-field=\"fld_5624415\"\n                                id=\"fld_5624415_1_opt1864046\"\n                                class=\"fld_5624415_1\"\n                                name=\"fld_5624415[opt1864046]\"\n                                value=\"Psychologist\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_5624415_1\"\n                                                                data-calc-value=\"Psychologist\"\n                            >\n                    Psychologist                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_103552\" class=\"form-group\" id=\"fld_103552_1-wrap\">\r\n\t<label id=\"fld_103552Label\" for=\"fld_103552_1\" class=\"control-label\">Assistance granted<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1113856\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Ambulance\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1113856\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1113856]\"\n                                value=\"Ambulance\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Ambulance\"\n                            >\n                    Ambulance                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1158316\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Fire fighter\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1158316\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1158316]\"\n                                value=\"Fire fighter\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Fire fighter\"\n                            >\n                    Fire fighter                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1817909\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Family\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1817909\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1817909]\"\n                                value=\"Family\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Family\"\n                            >\n                    Family                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1968762\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Friend\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1968762\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1968762]\"\n                                value=\"Friend\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Friend\"\n                            >\n                    Friend                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1389019\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Medical institutions\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1389019\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1389019]\"\n                                value=\"Medical institutions\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Medical institutions\"\n                            >\n                    Medical institutions                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1244649\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Social workers\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1244649\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1244649]\"\n                                value=\"Social workers\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Social workers\"\n                            >\n                    Social workers                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1087788\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Police\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1087788\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1087788]\"\n                                value=\"Police\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Police\"\n                            >\n                    Police                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1572663\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Psychiatrist\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1572663\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1572663]\"\n                                value=\"Psychiatrist\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Psychiatrist\"\n                            >\n                    Psychiatrist                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_103552_1_opt1864046\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Psychologist\"\n                                data-field=\"fld_103552\"\n                                id=\"fld_103552_1_opt1864046\"\n                                class=\"fld_103552_1\"\n                                name=\"fld_103552[opt1864046]\"\n                                value=\"Psychologist\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_103552_1\"\n                                                                data-calc-value=\"Psychologist\"\n                            >\n                    Psychologist                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-5  last_col\"><div data-field-wrapper=\"fld_8823327\" class=\"form-group\" id=\"fld_8823327_1-wrap\">\r\n<label id=\"fld_8823327Label\" for=\"fld_8823327_1\" class=\"control-label\">Permission to add your name in the TI map<\/label>\r\n<div class=\"\">\r\n\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"Yes\" for=\"fld_8823327_1_opt679269\"><input type=\"radio\" id=\"fld_8823327_1_opt679269\" data-field=\"fld_8823327\" class=\"fld_8823327_1\" name=\"fld_8823327\" value=\"Yes\" checked=\"checked\"   data-radio-field=\"fld_8823327_1\" data-type=\"radio\" data-calc-value=\"Yes\" \/>\n\t\t\tYes\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"radio\">\n\t\t\t\t<label data-label=\"No\" for=\"fld_8823327_1_opt1273204\"><input type=\"radio\" id=\"fld_8823327_1_opt1273204\" data-field=\"fld_8823327\" class=\"fld_8823327_1\" name=\"fld_8823327\" value=\"No\"    data-radio-field=\"fld_8823327_1\" data-type=\"radio\" data-calc-value=\"No\" \/>\n\t\t\tNo\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-9\"  class=\"row \"><div  class=\"col-sm-5  first_col\"><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_3914529_1\" data-field-id=\"fld_3914529_1\"><div data-field-wrapper=\"fld_3914529\" class=\"form-group\" id=\"fld_3914529_1-wrap\">\r\n\t<label id=\"fld_3914529Label\" for=\"fld_3914529_1\" class=\"control-label screen-reader-text sr-only\">Notes_hidden<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3914529\" value=\"\" data-field=\"fld_3914529\" class=\"form-control\" id=\"fld_3914529_1\" rows=\"2\" placeholder=\"If you want to write anything extra please tik YES button and a text field will appear. \"    aria-labelledby=\"fld_3914529Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/span><span class=\"caldera-forms-conditional-field\" role=\"region\" aria-live=\"polite\" id=\"conditional_fld_1177144_1\" data-field-id=\"fld_1177144_1\"><\/span><\/div><div  class=\"col-sm-1 \"><div data-field-wrapper=\"fld_2703341\" class=\"form-group\" id=\"fld_2703341_1-wrap\">\r\n\t<label id=\"fld_2703341Label\" for=\"fld_2703341_1\" class=\"control-label screen-reader-text sr-only\">Yes<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_2703341_1_opt1822516\"\n                >\n                            <input\n                                                                type=\"checkbox\"\n                                data-label=\"Yes\"\n                                data-field=\"fld_2703341\"\n                                id=\"fld_2703341_1_opt1822516\"\n                                class=\"fld_2703341_1\"\n                                name=\"fld_2703341[opt1822516]\"\n                                value=\"Yes\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_2703341_1\"\n                                                                data-calc-value=\"Yes\"\n                            >\n                    Yes                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_8077073\" class=\"form-group\" id=\"fld_8077073_1-wrap\">\r\n\t<label id=\"fld_8077073Label\" for=\"fld_8077073_1\" class=\"control-label\">Was this site useful<\/label>\r\n\t<div class=\"\">\r\n\t\t<div style=\"position: relative;\">\n\t\t\t<div id=\"fld_8077073_1_stars\" style=\"color:#AFAFAF;font-size:13px;\" ><\/div>\n\t\t\t<input type=\"text\" name=\"fld_8077073\" data-field=\"fld_8077073\" class=\"form-control\" id=\"fld_8077073_1\" value=\"0\" data-type=\"star\"   style=\"position: absolute; width: 0px; height: 0px; padding: 0px; bottom: 0px; left: 12px; opacity: 0; z-index: -1000;\" value=\"\" \/>\n\t\t<\/div>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3  last_col\"><div data-field-wrapper=\"fld_6457542\" class=\"form-group\" id=\"fld_6457542_1-wrap\">\r\n\t<label id=\"fld_6457542Label\" for=\"fld_6457542_1\" class=\"control-label\">How was site assembling<\/label>\r\n\t<div class=\"\">\r\n\t\t<div style=\"position: relative;\">\n\t\t\t<div id=\"fld_6457542_1_stars\" style=\"color:#AFAFAF;font-size:13px;\" ><\/div>\n\t\t\t<input type=\"text\" name=\"fld_6457542\" data-field=\"fld_6457542\" class=\"form-control\" id=\"fld_6457542_1\" value=\"0\" data-type=\"star\"   style=\"position: absolute; width: 0px; height: 0px; padding: 0px; bottom: 0px; left: 12px; opacity: 0; z-index: -1000;\" value=\"\" \/>\n\t\t<\/div>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5f30eb7c95cca_1-row-10\"  class=\"row  last_row\"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_4294375\" class=\"form-group submit_button\" id=\"fld_4294375_1-wrap\">\r\n\t<label class=\"control-label\">&nbsp;<\/label>\n<div class=\"\">\r\n\t<input  class=\"submit_button\" type=\"submit\" name=\"fld_4294375\" id=\"fld_4294375_1\" value=\"Submit\" data-field=\"fld_4294375\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_4294375\" id=\"fld_4294375_1_btn\" value=\"\" data-field=\"fld_4294375\"  \/>\n<\/div><\/div><\/form>\r\n<\/div>\r\n<script type=\"text\/javascript\">\r\nif( typeof caldera_conditionals === \"undefined\" ){ var caldera_conditionals = {}; }caldera_conditionals.CF5f30eb7c95cca_1 = {\"fld_5658413_1\":{\"type\":\"disable\",\"group\":{\"rw_ssshcixsm\":{\"cl_celvo\":{\"id\":\"cl_celvo\",\"field\":\"fld_4635733\",\"value\":\"Tooth\",\"compare\":\"is\",\"parent\":\"rw_ssshcixsm\",\"label\":\"Tooth\"}},\"rw_yvopegzm\":{\"cl_xvaijrzg\":{\"id\":\"cl_xvaijrzg\",\"field\":\"fld_4635733\",\"value\":\"Bone\",\"compare\":\"is\",\"parent\":\"rw_yvopegzm\",\"label\":\"Bone\"}},\"rw_vyokmkhjwa\":{\"cl_fxjokkh\":{\"id\":\"cl_fxjokkh\",\"field\":\"fld_4635733\",\"value\":\"Headache\",\"compare\":\"is\",\"parent\":\"rw_vyokmkhjwa\",\"label\":\"Headache\"}},\"rw_vxabxmf\":{\"cl_vtuzer\":{\"id\":\"cl_vtuzer\",\"field\":\"fld_4635733\",\"value\":\"Eye\",\"compare\":\"is\",\"parent\":\"rw_vxabxmf\",\"label\":\"Eye\"}},\"rw_oahvghog\":{\"cl_bsgekjae\":{\"id\":\"cl_bsgekjae\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"is\",\"parent\":\"rw_oahvghog\",\"label\":\"Muscle\"}},\"rw_qtyyfl\":{\"cl_lqcfccahd\":{\"id\":\"cl_lqcfccahd\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"is\",\"parent\":\"rw_qtyyfl\",\"label\":\"Muscle\"}},\"rw_nqmbirv\":{\"cl_ozscxas\":{\"id\":\"cl_ozscxas\",\"field\":\"fld_4635733\",\"value\":\"Bone\",\"compare\":\"isnot\",\"parent\":\"rw_nqmbirv\",\"label\":\"Bone\"}},\"rw_qmylor\":{\"cl_shcmcgcukg\":{\"id\":\"cl_shcmcgcukg\",\"field\":\"fld_4635733\",\"value\":\"Eye\",\"compare\":\"isnot\",\"parent\":\"rw_qmylor\",\"label\":\"Eye\"}},\"rw_iziljpki\":{\"cl_cnksjeil\":{\"id\":\"cl_cnksjeil\",\"field\":\"fld_4635733\",\"value\":\"Headache\",\"compare\":\"isnot\",\"parent\":\"rw_iziljpki\",\"label\":\"Headache\"}},\"rw_lgmtk\":{\"cl_udfqtwic\":{\"id\":\"cl_udfqtwic\",\"field\":\"fld_4635733\",\"value\":\"Heart\",\"compare\":\"isnot\",\"parent\":\"rw_lgmtk\",\"label\":\"Heart\"}},\"rw_vhrqzucr\":{\"cl_unawusfk\":{\"id\":\"cl_unawusfk\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"isnot\",\"parent\":\"rw_vhrqzucr\",\"label\":\"Muscle\"}},\"rw_skpdamudhd\":{\"cl_ftzpcgds\":{\"id\":\"cl_ftzpcgds\",\"field\":\"fld_4635733\",\"value\":\"Tooth\",\"compare\":\"isnot\",\"parent\":\"rw_skpdamudhd\",\"label\":\"Tooth\"}}}},\"fld_4029722_1\":{\"type\":\"show\",\"group\":{\"rw_scxiqrm\":{\"cl_qxemgxpa\":{\"id\":\"cl_qxemgxpa\",\"field\":\"fld_9760123\",\"value\":\"Other Reason\",\"compare\":\"is\",\"parent\":\"rw_scxiqrm\",\"label\":\"Other Reason\"}}}},\"fld_7226278_1\":{\"type\":\"disable\",\"group\":{\"rw_ssshcixsm\":{\"cl_celvo\":{\"id\":\"cl_celvo\",\"field\":\"fld_4635733\",\"value\":\"Tooth\",\"compare\":\"is\",\"parent\":\"rw_ssshcixsm\",\"label\":\"Tooth\"}},\"rw_yvopegzm\":{\"cl_xvaijrzg\":{\"id\":\"cl_xvaijrzg\",\"field\":\"fld_4635733\",\"value\":\"Bone\",\"compare\":\"is\",\"parent\":\"rw_yvopegzm\",\"label\":\"Bone\"}},\"rw_vyokmkhjwa\":{\"cl_fxjokkh\":{\"id\":\"cl_fxjokkh\",\"field\":\"fld_4635733\",\"value\":\"Headache\",\"compare\":\"is\",\"parent\":\"rw_vyokmkhjwa\",\"label\":\"Headache\"}},\"rw_vxabxmf\":{\"cl_vtuzer\":{\"id\":\"cl_vtuzer\",\"field\":\"fld_4635733\",\"value\":\"Eye\",\"compare\":\"is\",\"parent\":\"rw_vxabxmf\",\"label\":\"Eye\"}},\"rw_oahvghog\":{\"cl_bsgekjae\":{\"id\":\"cl_bsgekjae\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"is\",\"parent\":\"rw_oahvghog\",\"label\":\"Muscle\"}},\"rw_qtyyfl\":{\"cl_lqcfccahd\":{\"id\":\"cl_lqcfccahd\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"is\",\"parent\":\"rw_qtyyfl\",\"label\":\"Muscle\"}},\"rw_nqmbirv\":{\"cl_ozscxas\":{\"id\":\"cl_ozscxas\",\"field\":\"fld_4635733\",\"value\":\"Bone\",\"compare\":\"isnot\",\"parent\":\"rw_nqmbirv\",\"label\":\"Bone\"}},\"rw_qmylor\":{\"cl_shcmcgcukg\":{\"id\":\"cl_shcmcgcukg\",\"field\":\"fld_4635733\",\"value\":\"Eye\",\"compare\":\"isnot\",\"parent\":\"rw_qmylor\",\"label\":\"Eye\"}},\"rw_iziljpki\":{\"cl_cnksjeil\":{\"id\":\"cl_cnksjeil\",\"field\":\"fld_4635733\",\"value\":\"Headache\",\"compare\":\"isnot\",\"parent\":\"rw_iziljpki\",\"label\":\"Headache\"}},\"rw_lgmtk\":{\"cl_udfqtwic\":{\"id\":\"cl_udfqtwic\",\"field\":\"fld_4635733\",\"value\":\"Heart\",\"compare\":\"isnot\",\"parent\":\"rw_lgmtk\",\"label\":\"Heart\"}},\"rw_vhrqzucr\":{\"cl_unawusfk\":{\"id\":\"cl_unawusfk\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"isnot\",\"parent\":\"rw_vhrqzucr\",\"label\":\"Muscle\"}},\"rw_skpdamudhd\":{\"cl_ftzpcgds\":{\"id\":\"cl_ftzpcgds\",\"field\":\"fld_4635733\",\"value\":\"Tooth\",\"compare\":\"isnot\",\"parent\":\"rw_skpdamudhd\",\"label\":\"Tooth\"}}}},\"fld_3914529_1\":{\"type\":\"disable\",\"group\":{\"rw_ssshcixsm\":{\"cl_celvo\":{\"id\":\"cl_celvo\",\"field\":\"fld_4635733\",\"value\":\"Tooth\",\"compare\":\"is\",\"parent\":\"rw_ssshcixsm\",\"label\":\"Tooth\"}},\"rw_yvopegzm\":{\"cl_xvaijrzg\":{\"id\":\"cl_xvaijrzg\",\"field\":\"fld_4635733\",\"value\":\"Bone\",\"compare\":\"is\",\"parent\":\"rw_yvopegzm\",\"label\":\"Bone\"}},\"rw_vyokmkhjwa\":{\"cl_fxjokkh\":{\"id\":\"cl_fxjokkh\",\"field\":\"fld_4635733\",\"value\":\"Headache\",\"compare\":\"is\",\"parent\":\"rw_vyokmkhjwa\",\"label\":\"Headache\"}},\"rw_vxabxmf\":{\"cl_vtuzer\":{\"id\":\"cl_vtuzer\",\"field\":\"fld_4635733\",\"value\":\"Eye\",\"compare\":\"is\",\"parent\":\"rw_vxabxmf\",\"label\":\"Eye\"}},\"rw_oahvghog\":{\"cl_bsgekjae\":{\"id\":\"cl_bsgekjae\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"is\",\"parent\":\"rw_oahvghog\",\"label\":\"Muscle\"}},\"rw_qtyyfl\":{\"cl_lqcfccahd\":{\"id\":\"cl_lqcfccahd\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"is\",\"parent\":\"rw_qtyyfl\",\"label\":\"Muscle\"}},\"rw_nqmbirv\":{\"cl_ozscxas\":{\"id\":\"cl_ozscxas\",\"field\":\"fld_4635733\",\"value\":\"Bone\",\"compare\":\"isnot\",\"parent\":\"rw_nqmbirv\",\"label\":\"Bone\"}},\"rw_qmylor\":{\"cl_shcmcgcukg\":{\"id\":\"cl_shcmcgcukg\",\"field\":\"fld_4635733\",\"value\":\"Eye\",\"compare\":\"isnot\",\"parent\":\"rw_qmylor\",\"label\":\"Eye\"}},\"rw_iziljpki\":{\"cl_cnksjeil\":{\"id\":\"cl_cnksjeil\",\"field\":\"fld_4635733\",\"value\":\"Headache\",\"compare\":\"isnot\",\"parent\":\"rw_iziljpki\",\"label\":\"Headache\"}},\"rw_lgmtk\":{\"cl_udfqtwic\":{\"id\":\"cl_udfqtwic\",\"field\":\"fld_4635733\",\"value\":\"Heart\",\"compare\":\"isnot\",\"parent\":\"rw_lgmtk\",\"label\":\"Heart\"}},\"rw_vhrqzucr\":{\"cl_unawusfk\":{\"id\":\"cl_unawusfk\",\"field\":\"fld_4635733\",\"value\":\"Muscle\",\"compare\":\"isnot\",\"parent\":\"rw_vhrqzucr\",\"label\":\"Muscle\"}},\"rw_skpdamudhd\":{\"cl_ftzpcgds\":{\"id\":\"cl_ftzpcgds\",\"field\":\"fld_4635733\",\"value\":\"Tooth\",\"compare\":\"isnot\",\"parent\":\"rw_skpdamudhd\",\"label\":\"Tooth\"}}}},\"fld_1177144_1\":{\"type\":\"show\",\"group\":{\"rw_nnunjsy\":{\"cl_smlmjmakml\":{\"id\":\"cl_smlmjmakml\",\"field\":\"fld_2703341\",\"value\":\"Yes\",\"compare\":\"is\",\"parent\":\"rw_nnunjsy\",\"label\":\"Yes\"}}}}};\r\n<\/script>\r\n<script type=\"text\/html\" id=\"conditional-fld_4029722_1-tmpl\">\r\n<div data-field-wrapper=\"fld_4029722\" class=\"form-group\" id=\"fld_4029722_1-wrap\">\r\n\t<label id=\"fld_4029722Label\" for=\"fld_4029722_1\" class=\"control-label screen-reader-text sr-only\">ReasonExplanaton<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_4029722\" value=\"\" data-field=\"fld_4029722\" class=\"form-control\" id=\"fld_4029722_1\" rows=\"2\" placeholder=\"A brief explanation of the reason why you have become a TI.\"    aria-labelledby=\"fld_4029722Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\r\n<script type=\"text\/html\" id=\"conditional-fld_1177144_1-tmpl\">\r\n<div data-field-wrapper=\"fld_1177144\" class=\"form-group\" id=\"fld_1177144_1-wrap\">\r\n\t<label id=\"fld_1177144Label\" for=\"fld_1177144_1\" class=\"control-label screen-reader-text sr-only\">Notes<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_1177144\" value=\"\" data-field=\"fld_1177144\" class=\"form-control\" id=\"fld_1177144_1\"    aria-labelledby=\"fld_1177144Label\"><\/textarea>\n\t\t<\/div>\r\n<\/div>\r\n<\/script>\r\n\n<\/div>\n\t\t<\/div><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Description of some of the fields &#8211; Started: which year did your attacks begin (the first time you noticed you are a target). &#8211; Country: the country that you live in. Dropdowns: &#8211; Reason, what is your best guess that you&#8217;ve become a target. If your reason is not in the list you have two &hellip; <\/p>\n<p class=\"link-more\"><a href=\"https:\/\/targetedindividuals.ir\/index.php\/support\/survey\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &#8220;Survey&#8221;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":114,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"spay_email":"","footnotes":""},"_links":{"self":[{"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/pages\/136"}],"collection":[{"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/comments?post=136"}],"version-history":[{"count":47,"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/pages\/136\/revisions"}],"predecessor-version":[{"id":2490,"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/pages\/136\/revisions\/2490"}],"up":[{"embeddable":true,"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/pages\/114"}],"wp:attachment":[{"href":"https:\/\/targetedindividuals.ir\/index.php\/wp-json\/wp\/v2\/media?parent=136"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}