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Mater Hospital Ebola Self Reporting
E-mail to address
Custom:
Component:
Title
Symptoms Experienced:
Have you submitted an Employee Incident Report?
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
Form submissions will be e-mailed to this address. Any email, select, or hidden form element may be selected as the recipient address. Multiple e-mail addresses may be separated by commas.
Component e-mail options
Option
E-mail address
Dr.
Fr.
Miss.
Mr.
Mrs.
Ms.
Prof.
Sr.
The selected component
Title
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent to the corresponding address. If a field is left blank, no e-mail will be sent for that option.
Component e-mail options
Option
E-mail address
Fever
Nausea/Vomiting
Diarrhea
Headache
Joint or Muscle Pain, or both
Abdominal (stomach) Pain
Lack of Appetite
Weakness
The selected component
Symptoms Experienced:
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent to the corresponding address. If a field is left blank, no e-mail will be sent for that option.
Component e-mail options
Option
E-mail address
Yes
No
The selected component
Have you submitted an Employee Incident Report?
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent to the corresponding address. If a field is left blank, no e-mail will be sent for that option.
Component e-mail options
Option
E-mail address
Yes
No
The selected component
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent to the corresponding address. If a field is left blank, no e-mail will be sent for that option.
<p>Submitted on [submission:date:long]</p> <p>Submitted by anonymous user: [submission:ip-address]</p> <p>Submitted values are:</p> [submission:values] <p>The results of this submission may be viewed at:</p> <p>[submission:url]</p>
E-mail header details
E-mail subject
Default:
Form submission from: Mater Hospital Ebola Self Reporting
Custom:
Component:
Title
Firstname
Surname
Contact Telephone Number
Symptoms Experienced:
Have you submitted an Employee Incident Report?
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
Any textfield, select, or hidden form element may be selected as the subject for e-mails.
E-mail from address
Default:
noreply@webform.com
Custom:
Component:
Title
Symptoms Experienced:
Have you submitted an Employee Incident Report?
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
Any email, select, or hidden form element may be selected as the sender's e-mail address.
Component e-mail options
Option
E-mail address
Dr.
Fr.
Miss.
Mr.
Mrs.
Ms.
Prof.
Sr.
The selected component
Title
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent from the corresponding address.
Component e-mail options
Option
E-mail address
Fever
Nausea/Vomiting
Diarrhea
Headache
Joint or Muscle Pain, or both
Abdominal (stomach) Pain
Lack of Appetite
Weakness
The selected component
Symptoms Experienced:
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent from the corresponding address.
Component e-mail options
Option
E-mail address
Yes
No
The selected component
Have you submitted an Employee Incident Report?
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent from the corresponding address.
Component e-mail options
Option
E-mail address
Yes
No
The selected component
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
has multiple options. You may enter an e-mail address for each choice. When that choice is selected, an e-mail will be sent from the corresponding address.
E-mail from name
Default:
Webform.com
Custom:
Component:
Title
Firstname
Surname
Contact Telephone Number
Symptoms Experienced:
Have you submitted an Employee Incident Report?
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
Any textfield, select, or hidden form element may be selected as the sender's name for e-mails.
E-mail template
An e-mail template can customize the display of e-mails.
Default template
Custom template
<p>Submitted on [submission:date:long]</p> <p>Submitted by anonymous user: [submission:ip-address]</p> <p>Submitted values are:</p> [submission:values] <p>The results of this submission may be viewed at:</p> <p>[submission:url]</p>
Browse available tokens.
Send e-mail as HTML
Include files as attachments
Included e-mail values
The selected components will be included in the [submission:values] token. Individual values may still be printed if explicitly specified as a [submission:values:?] in the template.
Include all components
Title
Firstname
Surname
Contact Telephone Number
Date:
Time that you entered Unit:
Time that your duty finished:
Symptoms Experienced:
If you experienced any of the above, please define below the symptom, the date of onset and the duration of same:
If Fever is exhibited, what body temperature is recorded? (celcius)
Have you submitted an Employee Incident Report?
Have you contacted the Consultant in Occupational Medicine or the Department of Occupational Medicine CNM for personal consultation/triage prior to leaving the Unit?
Please Note:
