CHP BU - Cloud Pages - API Configurations - CHP PHIL Award - CHP PHIL Award API Form - Internal Testing


      <h2>CHP PHIL Award API Form - Internal Testing</h2>
      <form action="https://pages.upmc.com/chp-phil-award-api-internal-testing" method="post">
         <label>Nominee First Name</label>
         <input type="text" name="nominee_first_name"><br>
         <label>Nominee Last Name</label>
         <input type="text" name="nominee_last_name"><br>
         <label>Unit/Department</label>
         <input type="text" name="department"><br><br>
         <label>I am a(n):</label>
         <select name="nominee_relation" id="nominee_relation">
        <option value="" selected="selected">Select One</option>
        <option value="Patient">Patient</option>
        <option value="Family Member">Family Member</option>
        <option value="Visitor">Visitor</option>
        <option value="Physician">Physician</option>
        <option value="Employee">Employee</option>
      </select><br><br>
         <label>Your Name</label>
         <input type="text" name="your_name"><br>
         <label>Your Email Address</label>
         <input type="text" name="email_address"><br>
         <label>Your Phone Number</label>
         <input type="text" name="phone_number"><br><br>

         <label>Please Share Your Story</label>
      <textarea type="text" name="comments"></textarea><br> <br>

    <label>Please check one (Name Authorization)</label><br>
      <select name="name_authorization" id="name_authorization" multiple>
        <option value="I authorize my name to be used in hospital recognition materials for this respiratory therapist.
">I authorize my name to be used in hospital recognition materials for this respiratory therapist.
</option>
        <option value="I do not authorize my name to be used in hospital recognition materials for this respiratory therapist.">I do not authorize my name to be used in hospital recognition materials for this respiratory therapist.</option>
      </select><br><br>

         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br><br>
        
        <br>
        <div style="background-color:#96B8B9;padding:20px 15px 5px 15px;width:450px;">
          <label><strong>Captcha Score</strong></label>         <input type="text" name="captcha_score"><br>
            <ul>
                <li><strong>0-70</strong> will fire the TY email</li>
                <li><strong>71-80</strong> will fire the hcaptcha verification email</li>
                <li><strong>81 and above</strong> will destroy your life</li>
            </ul>
        </div>
        <br>
        
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>