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"other_org_input", "length": 255, "alias": "other_org_input", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "discipline_type", "length": 255, "alias": "discipline_type", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "site_location", "length": 255, "alias": "site_location", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "facility_combined", "length": 255, "alias": "facility_combined", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "single_relationship_combined", "length": 255, "alias": "relationship_combined", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "multi_relationship_combined", "length": 255, "alias": "relationship_combined", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "logo", "length": 255, "alias": "logo", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "welcome_note", "length": 255, "alias": "VCHCC Member Agreement", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "bylaws", "length": 255, "alias": "By completing this form, you agree to:", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "bylaws_agree", "length": 255, "alias": "bylaws_agree", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_coalition_note", "length": 255, "alias": " Primary Coalition Contact", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_coalitionname", "length": 255, "alias": "Name", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "contact_title", "length": 255, "alias": "Title", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_coalitionphone", "length": 255, "alias": "Phone Number", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_coalitionemail", "length": 255, "alias": "Email Address", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_contact_votingstatus", "type": "codedValue", "codedValues": [ { "code": "yes", "name": "Yes" }, { "code": "no", "name": "No" } ] }, "name": "contact_votingstatus", "length": 255, "alias": "Is this person a voting member?", 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}, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_facility", "length": 255, "alias": "Please enter the primary Site/Organization you are submitting this membership agreement for:", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_primary_other_org_select", "type": "codedValue", "codedValues": [ { "code": "other_org", "name": "Other Organization" } ] }, "name": "primary_other_org_select", "length": 255, "alias": "If your organization is not listed, choose \"Other Site/Organization\"", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_other_org_input", "length": 255, "alias": "Please type in the organization you are responding for.", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": 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"editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_primary_discipline_type_cbo", "type": "codedValue", "codedValues": [ { "code": "cbo_nonprofit", "name": "CBO & Non-Profit" }, { "code": "child_development", "name": "Child Development Center" }, { "code": "education", "name": "Educational Institution" }, { "code": "public_health", "name": "Public Health (non-direct care)" }, { "code": "other", "name": "Other" } ] }, "name": "primary_discipline_type_cbo", "length": 255, "alias": "Site/Organization Discipline Type", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_discipline_input", "length": 255, "alias": "If you selected other, please type in your Site/Organization Discipline", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_primary_siteadmin_same", "type": "codedValue", "codedValues": [ { "code": "primary", "name": "Primary Coalition Contact" }, { "code": "no", "name": "No - I need to input Site Adminstrator information" } ] }, "name": "primary_siteadmin_same", "length": 255, "alias": "Is your Site Administrator the same as your Primary Coalition Contact?", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_siteadmin_contact_name", "length": 255, "alias": "Name of Site Administrator", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_siteadmin_title", "length": 255, "alias": "Title", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_siteadmin_phone", "length": 255, "alias": "Phone Number", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_siteadmin_email", "length": 255, "alias": "Email Address", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_primary_emergency_same", "type": "codedValue", "codedValues": [ { "code": "primary", "name": "Primary Coalition Contact" }, { "code": "site_admin", "name": "Site Administrator" }, { "code": "no", "name": "No - I need to input an emergency contact" } ] }, "name": "primary_emergency_same", "length": 255, "alias": "Is your Emergency Contact the same as the Primary Coalition Contact or the Site Adminstrator?", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_primary_emergency_same_cbo", "type": "codedValue", "codedValues": [ { "code": "primary", "name": "Primary Coalition Contact" }, { "code": "no", "name": "No - I need to input an emergency contact" } ] }, "name": "primary_emergency_same_cbo", "length": 255, "alias": "Is your Emergency Contact the same as the Primary Coalition Contact?", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_emergency_contact_name", "length": 255, "alias": "Emergency Contact Name", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_emergency_title", "length": 255, "alias": "Title", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_emergency_phone", "length": 255, "alias": "Phone Number", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_emergency_email", "length": 255, "alias": "Email Address", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_primary_site_type_confirmation", "type": "codedValue", "codedValues": [ { "code": "yes_facility", "name": "This is a physical site that cares for patients." }, { "code": "yes_office", "name": "This is a location that does not directly care for patients." }, { "code": "no_facility", "name": "We do not currently have a physical location." } ] }, "name": "primary_site_type_confirmation", "length": 255, "alias": "Please confirm your physical site status before proceeding.", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_capacity", "alias": "What is your total licensed bed/patient capacity?", "type": "esriFieldTypeInteger" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_site_location", "length": 255, "alias": "Site Location", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "x_primary", "alias": "X", "type": "esriFieldTypeDouble" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "y_primary", "alias": "Y", "type": "esriFieldTypeDouble" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_247_phone", "length": 255, "alias": "24/7 Phone Number", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_site_fax", "length": 255, "alias": "Site Fax Number", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_site_sat_phone", "length": 255, "alias": "Site Satellite Phone Number", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_site_call_sign", "length": 255, "alias": "HAM Radio 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"esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_evac_site_phone", "length": 255, "alias": "Evacuation / Diversion Site Phone Number", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "primary_transportation", "length": 255, "alias": " Transportation", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_primary_vehicles", "type": "codedValue", "codedValues": [ { "code": "yes", "name": "Yes" }, { "code": "no", "name": "No" } ] }, "name": "primary_vehicles", "length": 255, "alias": "Do you have any facility or organization-owned vehicles?", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_multiplesites_confirm", "type": "codedValue", "codedValues": [ { "code": "yes", "name": "Yes" }, { "code": "no", "name": "No" } ] }, "name": "multiplesites_confirm", "length": 255, "alias": "Are you including additional sites in this form?", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "numberofsites", "alias": "Number of Additional Sites/Organizations included in this agreement", "type": "esriFieldTypeInteger" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": { "name": "service_7510b5dc6fce4497848abb2c115fb4ab_cvd_member_status", "type": "codedValue", "codedValues": [ { "code": "new_member", "name": "I am a new member of the HCC" }, { "code": "existing_member", "name": "I am an existing member of the HCC" } ] }, "name": "member_status", "length": 255, "alias": "What is your membership status?", "type": "esriFieldTypeString" }, { "nullable": true, "editable": true, "defaultValue": null, "domain": null, "name": "new_member_q", "length": 255, "alias": "What are some of the reasons you are joining the Coalition? 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