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Thalassemia Minor (trait) Screening Consent Form | Indian Red Cross Society
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field__item"><p>Please fill this form for Thalassemia Minor (trait) Screening</p> </div> <div class="field field--name-webform field--type-webform field--label-hidden field__item"><form class="webform-submission-form webform-submission-add-form webform-submission-thalassemia-screening-consent-fo-form webform-submission-thalassemia-screening-consent-fo-add-form webform-submission-thalassemia-screening-consent-fo-node-115-form webform-submission-thalassemia-screening-consent-fo-node-115-add-form js-webform-details-toggle webform-details-toggle" data-drupal-selector="webform-submission-thalassemia-screening-consent-fo-node-115-add-form" action="/ircs/bloodcentre/thalscreening" method="post" id="webform-submission-thalassemia-screening-consent-fo-node-115-add-form" accept-charset="UTF-8"> <div id="edit-name--wrapper" class="form-composite js-form-item form-item js-form-type-webform-name form-type-webform-name js-form-item-name form-item-name form-no-label"> <label for="edit-name" class="visually-hidden js-form-required form-required">Name</label> <fieldset data-drupal-selector="edit-name-title" class="js-webform-select-other webform-select-other fieldgroup form-composite required js-form-item form-item js-form-wrapper form-wrapper" id="edit-name-title--wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">Title</span> </legend> <div class="fieldset-wrapper"> <div class="js-form-item form-item js-form-type-select form-type-select js-form-item-name-title-select form-item-name-title-select form-no-label"> <select data-drupal-selector="edit-name-title-select" id="edit-name-title-select" name="name[title][select]" class="form-select required" required="required" aria-required="true"><option value="" selected="selected">- Select -</option><option value="Miss">Miss</option><option value="Ms">Ms</option><option value="Mr">Mr</option><option value="Mrs">Mrs</option><option value="Dr">Dr</option><option value="_other_">Other...</option></select> </div> <div class="js-webform-select-other-input webform-select-other-input js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-name-title-other form-item-name-title-other form-no-label"> <label for="edit-name-title-other" class="visually-hidden">Enter other...</label> <input data-drupal-selector="edit-name-title-other" type="text" id="edit-name-title-other" name="name[title][other]" value="" size="60" maxlength="128" placeholder="Enter other..." class="form-text" /> </div> </div> </fieldset> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-name-first form-item-name-first"> <label for="edit-name-first" class="js-form-required form-required">First Name</label> <input data-drupal-selector="edit-name-first" type="text" id="edit-name-first" name="name[first]" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true" /> </div> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-name-last form-item-name-last"> <label for="edit-name-last" class="js-form-required form-required">Last Name</label> <input data-drupal-selector="edit-name-last" type="text" id="edit-name-last" name="name[last]" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true" /> </div> </div> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-father-s-name-husband-s-name form-item-father-s-name-husband-s-name"> <label for="edit-father-s-name-husband-s-name" class="js-form-required form-required">Father's Name / Husband's Name</label> <input data-drupal-selector="edit-father-s-name-husband-s-name" type="text" id="edit-father-s-name-husband-s-name" name="father_s_name_husband_s_name" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true" /> </div> <div class="js-form-item form-item js-form-type-date form-type-date js-form-item-date-of-birth form-item-date-of-birth"> <label for="edit-date-of-birth" class="js-form-required form-required">Date of Birth</label> <input type="text" data-drupal-date-format="d/m/Y" data-drupal-selector="edit-date-of-birth" id="edit-date-of-birth" name="date_of_birth" value="" class="form-text required" required="required" aria-required="true" /> </div> <fieldset data-drupal-selector="edit-gender" id="edit-gender--wrapper" class="fieldgroup form-composite required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">Gender</span> </legend> <div class="fieldset-wrapper"> <div id="edit-gender" class="js-webform-radios webform-options-display-one-column form-radios"><div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-gender form-item-gender"> <input data-drupal-selector="edit-gender-male" type="radio" id="edit-gender-male" name="gender" value="Male" class="form-radio" /> <label for="edit-gender-male" class="option">Male</label> </div> <div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-gender form-item-gender"> <input data-drupal-selector="edit-gender-female" type="radio" id="edit-gender-female" name="gender" value="Female" class="form-radio" /> <label for="edit-gender-female" class="option">Female</label> </div> <div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-gender form-item-gender"> <input data-drupal-selector="edit-gender-others" type="radio" id="edit-gender-others" name="gender" value="Others" class="form-radio" /> <label for="edit-gender-others" class="option">Others</label> </div> </div> </div> </fieldset> <fieldset data-drupal-selector="edit-nationality" id="edit-nationality--wrapper" class="fieldgroup form-composite required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">Nationality</span> </legend> <div class="fieldset-wrapper"> <div id="edit-nationality" class="js-webform-radios webform-options-display-one-column form-radios"><div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-nationality form-item-nationality"> <input data-drupal-selector="edit-nationality-indian" type="radio" id="edit-nationality-indian" name="nationality" value="Indian" class="form-radio" /> <label for="edit-nationality-indian" class="option">Indian</label> </div> <div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-nationality form-item-nationality"> <input data-drupal-selector="edit-nationality-non-indian" type="radio" id="edit-nationality-non-indian" name="nationality" value="Non-Indian" class="form-radio" /> <label for="edit-nationality-non-indian" class="option">Non-Indian</label> </div> </div> </div> </fieldset> <fieldset data-drupal-selector="edit-marital-status" id="edit-marital-status--wrapper" class="fieldgroup form-composite required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">Marital Status</span> </legend> <div class="fieldset-wrapper"> <div id="edit-marital-status" class="js-webform-radios webform-options-display-one-column form-radios"><div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-marital-status form-item-marital-status"> <input data-drupal-selector="edit-marital-status-married" type="radio" id="edit-marital-status-married" name="marital_status" value="Married" class="form-radio" /> <label for="edit-marital-status-married" class="option">Married</label> </div> <div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-marital-status form-item-marital-status"> <input data-drupal-selector="edit-marital-status-unmarried" type="radio" id="edit-marital-status-unmarried" name="marital_status" value="Unmarried" class="form-radio" /> <label for="edit-marital-status-unmarried" class="option">Unmarried</label> </div> </div> </div> </fieldset> <div class="js-form-item form-item js-form-type-select form-type-select js-form-item-religion form-item-religion"> <label for="edit-religion" class="js-form-required form-required">Religion</label> <select data-drupal-selector="edit-religion" id="edit-religion" name="religion" class="form-select required" required="required" aria-required="true"><option value="" selected="selected">- Select -</option><option value="Hinduism">Hinduism</option><option value="Christianity">Christianity</option><option value="Islam">Islam</option><option value="Sikhism">Sikhism</option><option value="Jainism">Jainism</option><option value="Buddhism">Buddhism</option><option value="Others">Others</option></select> </div> <div class="js-form-item form-item js-form-type-select form-type-select js-form-item-community form-item-community"> <label for="edit-community" class="js-form-required form-required">Community</label> <select data-drupal-selector="edit-community" id="edit-community" name="community" class="form-select required" required="required" aria-required="true"><option value="" selected="selected">- Select -</option><option value="Sindhis">Sindhis</option><option value="Punjabis">Punjabis</option><option value="Gujaratis">Gujaratis</option><option value="Marwardis">Marwardis</option><option value="Bengalis">Bengalis</option><option value="Saraswats">Saraswats</option><option value="Gaurs">Gaurs</option><option value="Others">Others</option></select> </div> <div class="js-form-item form-item js-form-type-textarea form-type-textarea js-form-item-residential-address form-item-residential-address"> <label for="edit-residential-address" class="js-form-required form-required">Residential Address</label> <div class="form-textarea-wrapper"> <textarea data-drupal-selector="edit-residential-address" id="edit-residential-address" name="residential_address" rows="3" cols="60" class="form-textarea required resize-vertical" required="required" aria-required="true"></textarea> </div> </div> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-pin-code form-item-pin-code"> <label for="edit-pin-code" class="js-form-required form-required">Pin Code</label> <input data-drupal-selector="edit-pin-code" type="text" id="edit-pin-code" name="pin_code" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true" /> </div> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-telephone-number form-item-telephone-number"> <label for="edit-telephone-number">Telephone Number</label> <input data-drupal-selector="edit-telephone-number" type="text" id="edit-telephone-number" name="telephone_number" value="" size="60" maxlength="255" class="form-text" /> </div> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-mobile-number form-item-mobile-number"> <label for="edit-mobile-number" class="js-form-required form-required">Mobile Number</label> <input data-drupal-selector="edit-mobile-number" type="text" id="edit-mobile-number" name="mobile_number" value="" size="60" maxlength="255" class="form-text required" required="required" aria-required="true" /> </div> <div class="js-form-item form-item js-form-type-email form-type-email js-form-item-email-id form-item-email-id"> <label for="edit-email-id" class="js-form-required form-required">Email ID</label> <input data-drupal-selector="edit-email-id" type="email" id="edit-email-id" name="email_id" value="" size="60" maxlength="254" class="form-email required" required="required" aria-required="true" /> </div> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-occupation form-item-occupation"> <label for="edit-occupation">Occupation</label> <input data-drupal-selector="edit-occupation" type="text" id="edit-occupation" name="occupation" value="" size="60" maxlength="255" class="form-text" /> </div> <fieldset data-drupal-selector="edit-history-of-thalassemia-in-family" id="edit-history-of-thalassemia-in-family--wrapper" class="fieldgroup form-composite required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">History of Thalassemia in Family</span> </legend> <div class="fieldset-wrapper"> <div id="edit-history-of-thalassemia-in-family" class="js-webform-radios webform-options-display-one-column form-radios"><div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-history-of-thalassemia-in-family form-item-history-of-thalassemia-in-family"> <input data-drupal-selector="edit-history-of-thalassemia-in-family-yes" type="radio" id="edit-history-of-thalassemia-in-family-yes" name="history_of_thalassemia_in_family" value="Yes" class="form-radio" /> <label for="edit-history-of-thalassemia-in-family-yes" class="option">Yes</label> </div> <div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-history-of-thalassemia-in-family form-item-history-of-thalassemia-in-family"> <input data-drupal-selector="edit-history-of-thalassemia-in-family-no" type="radio" id="edit-history-of-thalassemia-in-family-no" name="history_of_thalassemia_in_family" value="No" class="form-radio" /> <label for="edit-history-of-thalassemia-in-family-no" class="option">No</label> </div> </div> </div> </fieldset> <fieldset data-drupal-selector="edit-history-of-blood-transfusion" id="edit-history-of-blood-transfusion--wrapper" class="fieldgroup form-composite required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">History of blood transfusion</span> </legend> <div class="fieldset-wrapper"> <div id="edit-history-of-blood-transfusion" class="js-webform-radios webform-options-display-one-column form-radios"><div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-history-of-blood-transfusion form-item-history-of-blood-transfusion"> <input data-drupal-selector="edit-history-of-blood-transfusion-yes" type="radio" id="edit-history-of-blood-transfusion-yes" name="history_of_blood_transfusion" value="Yes" class="form-radio" /> <label for="edit-history-of-blood-transfusion-yes" class="option">Yes</label> </div> <div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-history-of-blood-transfusion form-item-history-of-blood-transfusion"> <input data-drupal-selector="edit-history-of-blood-transfusion-no" type="radio" id="edit-history-of-blood-transfusion-no" name="history_of_blood_transfusion" value="No" class="form-radio" /> <label for="edit-history-of-blood-transfusion-no" class="option">No</label> </div> </div> </div> </fieldset> <fieldset data-drupal-selector="edit-marriage-among-cousins" id="edit-marriage-among-cousins--wrapper" class="fieldgroup form-composite required js-webform-type-radios webform-type-radios js-form-item form-item js-form-wrapper form-wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">Marriage among cousins</span> </legend> <div class="fieldset-wrapper"> <div id="edit-marriage-among-cousins" class="js-webform-radios webform-options-display-one-column form-radios"><div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-marriage-among-cousins form-item-marriage-among-cousins"> <input data-drupal-selector="edit-marriage-among-cousins-yes" type="radio" id="edit-marriage-among-cousins-yes" name="marriage_among_cousins" value="Yes" class="form-radio" /> <label for="edit-marriage-among-cousins-yes" class="option">Yes</label> </div> <div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-marriage-among-cousins form-item-marriage-among-cousins"> <input data-drupal-selector="edit-marriage-among-cousins-no" type="radio" id="edit-marriage-among-cousins-no" name="marriage_among_cousins" value="No" class="form-radio" /> <label for="edit-marriage-among-cousins-no" class="option">No</label> </div> </div> </div> </fieldset> <fieldset data-drupal-selector="edit-would-like-to-receive-report-through" id="edit-would-like-to-receive-report-through--wrapper" class="fieldgroup form-composite required js-webform-type-checkboxes webform-type-checkboxes js-form-item form-item js-form-wrapper form-wrapper" required="required" aria-required="true"> <legend> <span class="fieldset-legend js-form-required form-required">Would like to receive report through</span> </legend> <div class="fieldset-wrapper"> <div id="edit-would-like-to-receive-report-through" class="js-webform-checkboxes webform-options-display-one-column form-checkboxes"><div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-would-like-to-receive-report-through-email form-item-would-like-to-receive-report-through-email"> <input data-drupal-selector="edit-would-like-to-receive-report-through-email" type="checkbox" id="edit-would-like-to-receive-report-through-email" name="would_like_to_receive_report_through[Email]" value="Email" class="form-checkbox" /> <label for="edit-would-like-to-receive-report-through-email" class="option">Email</label> </div> <div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-would-like-to-receive-report-through-whatsapp form-item-would-like-to-receive-report-through-whatsapp"> <input data-drupal-selector="edit-would-like-to-receive-report-through-whatsapp" type="checkbox" id="edit-would-like-to-receive-report-through-whatsapp" name="would_like_to_receive_report_through[Whatsapp]" value="Whatsapp" class="form-checkbox" /> <label for="edit-would-like-to-receive-report-through-whatsapp" class="option">Whatsapp</label> </div> <div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-would-like-to-receive-report-through-courier form-item-would-like-to-receive-report-through-courier"> <input data-drupal-selector="edit-would-like-to-receive-report-through-courier" type="checkbox" id="edit-would-like-to-receive-report-through-courier" name="would_like_to_receive_report_through[Courier]" value="Courier" class="form-checkbox" /> <label for="edit-would-like-to-receive-report-through-courier" class="option">Courier</label> </div> <div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-would-like-to-receive-report-through-self-collection form-item-would-like-to-receive-report-through-self-collection"> <input data-drupal-selector="edit-would-like-to-receive-report-through-self-collection" type="checkbox" id="edit-would-like-to-receive-report-through-self-collection" name="would_like_to_receive_report_through[Self collection]" value="Self collection" class="form-checkbox" /> <label for="edit-would-like-to-receive-report-through-self-collection" class="option">Self collection</label> </div> </div> </div> </fieldset> <div id="edit-markup" class="js-form-item form-item js-form-type-webform-markup form-type-webform-markup js-form-item- form-item- form-no-label"> <span><span><span><strong><span lang="EN-US">Note</span></strong><span lang="EN-US">: <br /> <span><span>- Above mention information is for the purpose of analysis only and will be kept confidential.<br /> <span><span><span lang="EN-US">- In case of “Positive” result for Thalassemia minor, all the members of the family need to be tested for Thalassemia</span>.<br /> <span><span>- The report of this test will not be valid for any medico legal case.</span></span></span></span></span></span></span></span></span></span> </div> <div data-webform-terms-of-service-type="modal" class="form-type-webform-terms-of-service js-form-type-webform-terms-of-service js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-terms-of-service form-item-terms-of-service"> <input data-drupal-selector="edit-terms-of-service" type="checkbox" id="edit-terms-of-service" name="terms_of_service" value class="form-checkbox required" required="required" aria-required="true" /> <label for="edit-terms-of-service" class="option js-form-required form-required">I agree to the <a>terms of service</a>.</label> <div id="edit-terms-of-service--description" class="description"> <div class="webform-terms-of-service-details js-hide"><div class="webform-terms-of-service-details--title">Consent</div><div class="webform-terms-of-service-details--content"><span lang="EN-US"><span>I have come to know the basic knowledge of Thalassemia through counselling, IEC (information by electronics and communication) material supplied by Indian Red Cross Society (NHQ), New Delhi. I have been also informed that the blood sample shall be collected only for Thalassemia screening</span></span></div></div> </div> </div> <input autocomplete="off" data-drupal-selector="form-onyy-u77vvbpj0a9-gwxe8qs0ru2xv5dxycsivlpfhi" type="hidden" name="form_build_id" value="form-OnYy-u77vVBPJ0a9_gwXe8qs0RU2xV5DxYcSIvlpFhI" /> <input data-drupal-selector="edit-webform-submission-thalassemia-screening-consent-fo-node-115-add-form" type="hidden" name="form_id" value="webform_submission_thalassemia_screening_consent_fo_node_115_add_form" /> <div data-drupal-selector="edit-captcha" class="captcha"><input data-drupal-selector="edit-captcha-sid" type="hidden" name="captcha_sid" value="6893" /> <input data-drupal-selector="edit-captcha-token" type="hidden" name="captcha_token" value="IB3TSd5EJnJIpaRUtqwWJe7JeWSS3cJTfVBp4Pd7VqY" /> <img data-drupal-selector="edit-captcha-image" src="/ircs/image-captcha-generate/6893/1732358540" width="180" height="60" alt="Image CAPTCHA" title="Image CAPTCHA" typeof="foaf:Image" /> <div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-captcha-response form-item-captcha-response"> <label for="edit-captcha-response" class="js-form-required form-required">What code is in the image?</label> <input autocomplete="off" data-drupal-selector="edit-captcha-response" aria-describedby="edit-captcha-response--description" type="text" id="edit-captcha-response" name="captcha_response" value="" size="15" maxlength="128" class="form-text required" required="required" aria-required="true" /> <div id="edit-captcha-response--description" class="description"> Enter the characters shown in the image. </div> </div> </div> <div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions"><input class="webform-button--submit button button--primary js-form-submit form-submit" data-drupal-selector="edit-submit" type="submit" id="edit-submit" name="op" value="Submit" /> </div> 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