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18.244.18.6  Public Scan

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1 forms found in the DOM

Name: surveyForm — POST

<form name="surveyForm" action="" method="post" enctype="multipart/form-data" novalidate="" data-survey-page-form="">
  <div class="questions clearfix">
    <div class="question-click-shield" tabindex="-1" style="height: 231px; width: 896px; display: none;"></div>
    <div class="question-row clearfix" tabindex="-1">
      <div data-question-type="presentation_descriptive_text" data-rq-question-type="presentation_text" class="question-container
    
    ">
        <div id="question-field-197341296" data-qnumber="1" data-qdispnumber="" data-question-id="197341296" class=" question-presentation-text qn question descriptive_text">
          <div class="question-body-font-theme question-presentation-text user-generated">
            <span class="user-generated notranslate
                ">
              <span style="font-size: 14pt;">SIS Research is conducting online Zoom interviews to explore the market potential and clinical utility of a <strong>new portable device designed to measure fibrinogen levels</strong> at the point of
                care.</span><br><br><span style="font-size: 14pt;">We provide <strong>$150</strong> if you qualify, are selected, and complete an approximately 30-minute Zoom interview. </span><br><br><span style="font-size: 14pt;">Please answer the
                pre-screener questions below to see if you are a fit for the study. We will contact you if you qualify.</span><br><br><span style="font-size: 14pt;">Thank you!</span></span>
          </div>
        </div>
      </div>
      <button id="197341296-ok" class="new-button ok-button user-generated notranslate" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 81px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-197340885" data-qnumber="2" data-qdispnumber="1" data-question-id="197340885" class=" question-open-ended-single qn question single question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-197340885" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 1<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> Name</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_197340885" data-question-id="197340885" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-required="true" data-size="50" data-labeledby="question-title-197340885">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-197340885" id="197340885" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="197340885" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="197340885-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 81px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-197340886" data-qnumber="3" data-qdispnumber="2" data-question-id="197340886" class=" question-open-ended-single qn question single question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-197340886" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 2<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> Email</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_197340886" data-question-id="197340886" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-required="true" data-size="50" data-labeledby="question-title-197340886">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-197340886" id="197340886" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="197340886" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="197340886-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 80px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-199590204" data-qnumber="4" data-qdispnumber="3" data-question-id="199590204" class=" question-open-ended-single qn question single">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-199590204" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 3<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> LinkedIn (For verification)</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_199590204" data-question-id="199590204" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-size="50" data-labeledby="question-title-199590204">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-199590204" id="199590204" aria-required="false" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="199590204" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="199590204-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 81px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-197340887" data-qnumber="5" data-qdispnumber="4" data-question-id="197340887" class=" question-open-ended-single qn question single question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-197340887" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 4<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> Phone Number</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_197340887" data-question-id="197340887" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-required="true" data-size="50" data-labeledby="question-title-197340887">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-197340887" id="197340887" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="197340887" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="197340887-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 81px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-197340888" data-qnumber="6" data-qdispnumber="5" data-question-id="197340888" class=" question-open-ended-single qn question single question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-197340888" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 5<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> What is your current place of residence?</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_197340888" data-question-id="197340888" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-required="true" data-size="50" data-labeledby="question-title-197340888">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-197340888" id="197340888" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="197340888" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="197340888-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 248px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
    
    ">
        <div id="question-field-197340889" data-qnumber="7" data-qdispnumber="6" data-question-id="197340889" class=" question-single-choice-radio qn question vertical question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <fieldset class=" question-fieldset" data-radio-button-group="">
            <legend class="question-legend">
              <h4 id="question-title-197340889" class="
                     question-title-container ">
                <span class="required-asterisk notranslate"> * </span>
                <span class="question-number notranslate"> 6<span class="question-dot">.</span>
                </span>
                <span class="user-generated notranslate
                "> What is your current professional role?</span>
              </h4>
            </legend>
            <div class="question-body clearfix notranslate ">
              <div class="">
                <div class="answer-option-cell" data-answer-id="1421124306">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340889">
                    <input id="197340889_1421124306" aria-labelledby="197340889_1421124306_label" name="197340889" type="radio" role="radio" class="radio-button-input " value="1421124306" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340889_1421124306_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340889_1421124306">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> Physician </span>
                    </label>
                  </div>
                </div>
                <div class="answer-option-cell" data-answer-id="1421124307">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340889">
                    <input id="197340889_1421124307" aria-labelledby="197340889_1421124307_label" name="197340889" type="radio" role="radio" class="radio-button-input " value="1421124307" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340889_1421124307_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340889_1421124307">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> Nurse </span>
                    </label>
                  </div>
                </div>
                <div class="answer-option-cell" data-answer-id="1421124308">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340889">
                    <input id="197340889_1421124308" aria-labelledby="197340889_1421124308_label" name="197340889" type="radio" role="radio" class="radio-button-input " value="1421124308" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340889_1421124308_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340889_1421124308">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> Clinical Laboratory Technician </span>
                    </label>
                  </div>
                </div>
              </div>
              <div class="other-answer-container other-answer-option-container" data-answer-id="1421128252">
                <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340889">
                  <input id="197340889_1421128252" aria-labelledby="197340889_1421128252_label" name="197340889" type="radio" role="radio" class="radio-button-input " value="1421128252" aria-checked="false" data-other-answer="">
                  <label data-sm-radio-button-label="" id="197340889_1421128252_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340889_1421128252">
                    <span class="radio-button-display ">
                    </span>
                    <span class="radio-button-label-text question-body-font-theme user-generated "> Other healthcare professional (Please specify) </span>
                  </label>
                </div>
                <input id="197340889_other" name="197340889_other" type="text" class="text other-answer-text" maxlength="20000" size="50" aria-label="Other healthcare professional (Please specify)" data-other-text="">
              </div>
              <div class="nota-row-container ">
                <div class="answer-option-cell" data-answer-id="1421128251">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340889">
                    <input id="197340889_1421128251" aria-labelledby="197340889_1421128251_label" name="197340889" type="radio" role="radio" class="radio-button-input " value="1421128251" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340889_1421128251_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340889_1421128251">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> I don't work in the healthcare industry </span>
                    </label>
                  </div>
                </div>
              </div>
            </div>
          </fieldset>
        </div>
      </div>
      <button id="197340889-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 80px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-197340890" data-qnumber="8" data-qdispnumber="7" data-question-id="197340890" class=" question-open-ended-single qn question single">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-197340890" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 7<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> What is your medical specialty? (only if it applies)</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_197340890" data-question-id="197340890" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-size="50" data-labeledby="question-title-197340890">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-197340890" id="197340890" aria-required="false" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="197340890" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="197340890-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 81px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-197340891" data-qnumber="9" data-qdispnumber="8" data-question-id="197340891" class=" question-open-ended-single qn question single question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-197340891" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 8<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> What department do you work in?</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_197340891" data-question-id="197340891" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-required="true" data-size="50" data-labeledby="question-title-197340891">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-197340891" id="197340891" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="197340891" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="197340891-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 81px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
    ">
        <div id="question-field-197340892" data-qnumber="10" data-qdispnumber="9" data-question-id="197340892" class=" question-open-ended-single qn question single question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-197340892" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 9<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> What is the name of the hospital or company at which you currently work?</span>
            </h4>
            <div class="question-body clearfix notranslate ">
              <div id="open-ended-single_197340892" data-question-id="197340892" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-required="true" data-size="50" data-labeledby="question-title-197340892">
                <div class="question-body open-ended-single"><input aria-labelledby="question-title-197340892" id="197340892" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="197340892" size="50" value=""></div>
              </div>
            </div>
          </div>
        </div>
      </div>
      <button id="197340892-ok" class="new-button ok-button user-generated notranslate hide" type="submit"> OK </button>
    </div>
    <div class="question-click-shield" tabindex="-1" style="height: 206px; width: 896px;"></div>
    <div class="question-row clearfix overlay
                   " tabindex="-1">
      <div data-question-type="single_choice_vertical" data-rq-question-type="single_choice_vertical" class="question-container
    
    ">
        <div id="question-field-197340893" data-qnumber="11" data-qdispnumber="10" data-question-id="197340893" class=" question-single-choice-radio qn question vertical question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <fieldset class=" question-fieldset" data-radio-button-group="">
            <legend class="question-legend">
              <h4 id="question-title-197340893" class="
                     question-title-container ">
                <span class="required-asterisk notranslate"> * </span>
                <span class="question-number notranslate"> 10<span class="question-dot">.</span>
                </span>
                <span class="user-generated notranslate
                "> How many years of experience do you have in your current healthcare field?</span>
              </h4>
            </legend>
            <div class="question-body clearfix notranslate ">
              <div class="">
                <div class="answer-option-cell" data-answer-id="1421124310">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340893">
                    <input id="197340893_1421124310" aria-labelledby="197340893_1421124310_label" name="197340893" type="radio" role="radio" class="radio-button-input " value="1421124310" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340893_1421124310_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340893_1421124310">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> No experience </span>
                    </label>
                  </div>
                </div>
                <div class="answer-option-cell" data-answer-id="1421124311">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340893">
                    <input id="197340893_1421124311" aria-labelledby="197340893_1421124311_label" name="197340893" type="radio" role="radio" class="radio-button-input " value="1421124311" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340893_1421124311_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340893_1421124311">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> Less than 5 years </span>
                    </label>
                  </div>
                </div>
                <div class="answer-option-cell" data-answer-id="1421124312">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340893">
                    <input id="197340893_1421124312" aria-labelledby="197340893_1421124312_label" name="197340893" type="radio" role="radio" class="radio-button-input " value="1421124312" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340893_1421124312_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340893_1421124312">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> 5 to 10 years </span>
                    </label>
                  </div>
                </div>
                <div class="answer-option-cell" data-answer-id="1421124313">
                  <div data-sm-radio-button="" class="radio-button-container " aria-labelledby="question-title-197340893">
                    <input id="197340893_1421124313" aria-labelledby="197340893_1421124313_label" name="197340893" type="radio" role="radio" class="radio-button-input " value="1421124313" aria-checked="false">
                    <label data-sm-radio-button-label="" id="197340893_1421124313_label" class="answer-label radio-button-label no-touch touch-sensitive clearfix" for="197340893_1421124313">
                      <span class="radio-button-display ">
                      </span>
                      <span class="radio-button-label-text question-body-font-theme user-generated "> 10 to 20 years </span>
                    </label>
                  </div>
                </div>
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Text Content

FIBRINOGEN TESTING DEVICE


SCREENER SURVEY - GENERIC INFORMATION

SIS Research is conducting online Zoom interviews to explore the market
potential and clinical utility of a new portable device designed to measure
fibrinogen levels at the point of care.

We provide $150 if you qualify, are selected, and complete an approximately
30-minute Zoom interview.

Please answer the pre-screener questions below to see if you are a fit for the
study. We will contact you if you qualify.

Thank you!
OK



QUESTION TITLE

* 1. NAME


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QUESTION TITLE

* 2. EMAIL


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QUESTION TITLE

* 3. LINKEDIN (FOR VERIFICATION)


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QUESTION TITLE

* 4. PHONE NUMBER


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QUESTION TITLE

* 5. WHAT IS YOUR CURRENT PLACE OF RESIDENCE?


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QUESTION TITLE

* 6. WHAT IS YOUR CURRENT PROFESSIONAL ROLE?

Physician
Nurse
Clinical Laboratory Technician
Other healthcare professional (Please specify)
I don't work in the healthcare industry
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QUESTION TITLE

* 7. WHAT IS YOUR MEDICAL SPECIALTY? (ONLY IF IT APPLIES)


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QUESTION TITLE

* 8. WHAT DEPARTMENT DO YOU WORK IN?


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QUESTION TITLE

* 9. WHAT IS THE NAME OF THE HOSPITAL OR COMPANY AT WHICH YOU CURRENTLY WORK?


OK



QUESTION TITLE

* 10. HOW MANY YEARS OF EXPERIENCE DO YOU HAVE IN YOUR CURRENT HEALTHCARE FIELD?

No experience
Less than 5 years
5 to 10 years
10 to 20 years
More than 20 years
OK
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