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nethealth.secure.force.com Open in urlscan Pro
13.110.32.20  Public Scan

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Submitted URL: https://u26417145.ct.sendgrid.net/ls/click?upn=fZpuV-2BXJnJJSy-2B2ySwcouNnRWD5rq9o0ww3SUjSRaCwvsnKJm1CvleRutRLEOV6eXmkGwGH2soervNg...
Effective URL: https://nethealth.secure.force.com/forms/apex/VisualAntidote__HostedFastForm?f=j4I4Jpc6AiEQZnshzBgQ6TvOb6HDvwUDYP%2BpG0kDIlWnBoGgjm...
Submission: On November 21 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://nethealth.secure.force.com/forms/apex/MultiPartEndpoint?encoding=UTF-8

<form action="https://nethealth.secure.force.com/forms/apex/MultiPartEndpoint?encoding=UTF-8" enctype="multipart/form-data" id="form1" method="post" target="ffIframe">
  <input id="userTimeZone" type="hidden" value="0">
  <input id="txtObjId" type="hidden" value="">
  <input id="txtHtmlId" type="hidden" value="">
  <input id="formHtml" type="hidden">
  <input id="txtSessionID" type="hidden" value="">
  <input class="ignore-submit" id="txtSubmittedData" type="hidden" value="">
  <input id="multipageEnabled" type="hidden" value="false">
  <input id="googleCaptchaEnabled" type="hidden" value="false">
  <input id="breadcrumbEnabled" type="hidden" value="false">
  <input id="breadcrumbNumbered" type="hidden" value="false">
  <input id="breadcrumbPrefix" type="hidden" value="">
  <input id="submitMessage" type="hidden" value="Thank you for your submission!">
  <input id="submitUrl" type="hidden" value="">
  <input id="submitBtnText" type="hidden" value="Send">
  <input id="prevBtnText" type="hidden" value="Back">
  <input id="nextBtnText" type="hidden" value="Next">
  <input id="pageValType" type="hidden" value="form">
  <input id="txtUserContentId" type="hidden" value="">
  <input id="hasCustomCSS" type="hidden" value="true">
  <input id="isCurrentForm" type="hidden" value="false">
  <input id="isDraft" type="hidden" value="false">
  <input id="saveForLaterEnabled" type="hidden" value="false">
  <input id="saveBtnText" type="hidden" value="Save">
  <input id="discardBtnText" type="hidden" value="Discard">
  <input id="draftSaved" type="hidden" value="false">
  <input id="draftEmail" type="hidden">
  <input id="paymentType" type="hidden" value="">
  <input class="ignore-submit" id="ruleFieldsMap" type="hidden" value="{&quot;Case.Received_from_Formstack__c&quot;:&quot;2||false&quot;,&quot;Case.Subject&quot;:&quot;1||false&quot;}">
  <input class="ignore-submit" id="relatedFieldsMapJSON" type="hidden" value="">
  <input class="ignore-submit" id="staticPrefillParams" type="hidden" value="{}">
  <input id="formName" type="hidden" value="">
  <input id="formId" type="hidden" value="a8A4M0000004JIDUA2">
  <input id="prefillObj" type="hidden" value="">
  <input id="accessToken" type="hidden" value="4gilPD5UCa61nKs6DUcPd/G4F4L+O1STQltORIG+IbA74KNPlbbpfE2gTs5DbcheK60CjoU/cxP6aVgVnWDJfy1S2DWIaUTEUeiorqVneOtMR3/jhIspnl1twVKzOf3+3iNeCKkyrvmfCLey4JYF4iIWM88U7rCpUSJityzAyxQ=">
  <input id="dateFormat" type="hidden" value="mm/dd/yy">
  <input id="todayDate" type="hidden" value="Mon Nov 21 00:00:00 GMT 2022">
  <input id="userLocal" type="hidden" value="en_US">
  <input id="jsCode" type="hidden" value="function FF_OnAfterRender() { FFEvaluateRules(); }
function FF_OnBeforeSave() {
    if (fs(&amp;#39;#inputContact\\.Case\\.A\\.AccountId&amp;#39;).val() !== &amp;#39;Other&amp;#39;) {
        fs(&amp;#39;#Contact\\.LastName&amp;#39;).val(fs(&amp;#39;#inputContact\\.Case\\.A\\.AccountId&amp;#39;).val());
    }

    return true;
}">
  <input id="ipAddress" type="hidden" value="37.58.58.248">
  <input id="recaptchaSiteKey" type="hidden" value="6Lc18EwUAAAAAOB_uHmFppxqGckUWnMwK0h3fsdp">
  <input id="submitRules" type="hidden">
  <input id="hfFileServiceEndpoint" name="hfFileServiceEndpoint" type="hidden" value="https://sfapi.formstack.io">
  <input id="hfFileServiceApiKey" name="hfFileServiceApiKey" type="hidden" value="8fc5982e-6eca-4d73-a3ff-997902b163b0-20212151122">
  <input id="fsListFileUploadedJSON" name="fsListFileUploadedJSON" type="hidden" value="[]">
  <input id="CommunityInstanceURL" type="hidden" value="">
  <input id="CommunitySessioID" type="hidden" value="">
  <input id="CommunityUserId" type="hidden" value="">
  <input id="CommunityUserType" type="hidden" value="">
  <input id="CommunityViewMode" type="hidden" value="">
  <input id="comPrefillDataset" type="hidden"
    value="{&quot;StatusCode&quot;:null,&quot;ResultText&quot;:&quot;[{\&quot;prefillSource\&quot;:null,\&quot;objectName\&quot;:\&quot;Case\&quot;,\&quot;objectFieldRootIdentifier\&quot;:\&quot;Case.\&quot;,\&quot;jsonListResults\&quot;:\&quot;[{\\\&quot;attributes\\\&quot;:{\\\&quot;type\\\&quot;:\\\&quot;Case\\\&quot;,\\\&quot;url\\\&quot;:\\\&quot;/services/data/v56.0/sobjects/Case/4Fv9sA5azaSnNu3OVpS0Viwa7Eiwy90noqAzQLg4J0c%3D\\\&quot;},\\\&quot;BusinessHoursId\\\&quot;:\\\&quot;01m61000000EKh1AAG\\\&quot;,\\\&quot;OwnerId\\\&quot;:\\\&quot;0054M000004jgJGQAY\\\&quot;,\\\&quot;Id\\\&quot;:\\\&quot;4Fv9sA5azaSnNu3OVpS0Viwa7Eiwy90noqAzQLg4J0c=\\\&quot;,\\\&quot;Point_of_Service_Survey_Response__c\\\&quot;:10.0,\\\&quot;Case_Owner_Name__c\\\&quot;:\\\&quot;Ruth Shields\\\&quot;,\\\&quot;Received_from_Formstack__c\\\&quot;:true,\\\&quot;Salesforce_Case_Number__c\\\&quot;:\\\&quot;00770536\\\&quot;,\\\&quot;Subject\\\&quot;:\\\&quot;PROD 11-12 -- FW: Payor - MTI\\\&quot;}]\&quot;}]&quot;,&quot;ResultSObject&quot;:null,&quot;OtherText&quot;:&quot;{\&quot;primary\&quot;:\&quot;Case\&quot;}&quot;,&quot;IsValid&quot;:true,&quot;Headers&quot;:{}}">
  <input id="comPrefillObj" type="hidden"
    value="[{&quot;identifier&quot;:&quot;Case&quot;,&quot;rtype&quot;:&quot;primary&quot;,&quot;objectRootFieldIdentifier&quot;:&quot;Case.&quot;,&quot;ids&quot;:[&quot;4Fv9sA5azaSnNu3OVpS0Viwa7Eiwy90noqAzQLg4J0c=&quot;],&quot;isrepeated&quot;:false}]">
  <div id="dvBannerHTML" runat="server">
    <div id="j_id0:ffRules">
      <script data-js="fastforms" type="text/javascript" language="javascript">
        function evaluateRules(lstRules, source) {
          if (arguments.length > 0) {
            for (var i = 0; i < lstRules.length; i++) {
              switch (lstRules[i]) {
                case 1:
                  if ((!FFEqualTo('Case.Subject', '', false, source))) {
                    FFPopulate('GENERALTEXT297',
                      'Thank you for taking the time to tell us how we did assisting you with case <b>[[Case.Salesforce_Case_Number__c]] : [[Case.Subject]]</b> <br> <br> On a scale of 1 to 10, with 1 being the worst and 10 being awesome, please rate this experience with [[Case.Case_Owner_Name__c]].',
                      false, source);
                  }
                  break;
                case 2:
                  if ((FFEqualTo('Case.Received_from_Formstack__c', 'false', false, source))) {
                    FFPopulate('Case.Received_from_Formstack__c', 'true', false, source);
                  }
                  break;
              }
            }
          } else {
            if ((!FFEqualTo('Case.Subject', '', false, source))) {
              FFPopulate('GENERALTEXT297',
                'Thank you for taking the time to tell us how we did assisting you with case <b>[[Case.Salesforce_Case_Number__c]] : [[Case.Subject]]</b> <br> <br> On a scale of 1 to 10, with 1 being the worst and 10 being awesome, please rate this experience with [[Case.Case_Owner_Name__c]].',
                false, source);
            }
            if ((FFEqualTo('Case.Received_from_Formstack__c', 'false', false, source))) {
              FFPopulate('Case.Received_from_Formstack__c', 'true', false, source);
            }
          }
        }
      </script>
    </div>
    <div id="j_id0:j_id13" class="ff-form-main">
      <div id="ffOverlay"></div>
      <div id="ffPage30" class="ff-page-row page-1" data-pagetitle="Page Title">
        <div class="ff-group-row group-0" id="ffSection0">
          <div class="ff-item-row">
            <div class="ff-col-1 ff-section-col"><label class="ff-section-header" id="sectionLabel0"></label></div>
          </div>
          <div class="ff-item-row fw-row">
            <div class="ff-col-1 ff-label-col"><label id="GENERALTEXT297" class="ff-label ff-general-text-label" vatt="STRING" data-ishidden="false">Thank you for taking the time to tell us how we did assisting you with case
                <b>00770536 : PROD 11-12 -- FW: Payor - MTI</b> <br> <br> On a scale of 1 to 10, with 1 being the worst and 10 being awesome, please rate this experience with Ruth Shields.</label></div>
          </div>
          <div class="ff-item-row">
            <div class="ff-col-1 ff-label-col"><label vatt="DOUBLE(2,0)" for="Case.Point_of_Service_Survey_Response__c" class="ff-label" id="lblCasePoint_of_Service_Survey_Response__c">Star Rating</label><span
                class="requiredSpan ff-required-mark">*</span></div>
            <div class="ff-col-2 ff-field-col">
              <div class="ff-rating-widget star-rating-control custom-flex-control-container">
                <a href="#" title="1" data-rating-value="1" data-rating-text="1" class="ff-rating-selected"><span class="star-icon"></span><span class="rating-label-first">1</span></a><a href="#" title="2" data-rating-value="2" data-rating-text="2" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="3" data-rating-value="3" data-rating-text="3" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="4" data-rating-value="4" data-rating-text="4" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="5" data-rating-value="5" data-rating-text="5" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="6" data-rating-value="6" data-rating-text="6" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="7" data-rating-value="7" data-rating-text="7" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="8" data-rating-value="8" data-rating-text="8" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="9" data-rating-value="9" data-rating-text="9" class="ff-rating-selected"><span class="star-icon"></span><span></span></a><a href="#" title="10" data-rating-value="10" data-rating-text="10" class="ff-rating-selected ff-rating-current"><span class="star-icon"></span><span class="rating-label-last">10</span></a><span
                  class="ff-rating-current-rating">10</span></div><input type="textbox" id="Case.Point_of_Service_Survey_Response__c" placeholder="" aria-placeholder="" name="Case.Point_of_Service_Survey_Response__c" vatt="DOUBLE(2,0)"
                class="ff-input-type ff-type-text custom-flexcontrol-offscreen" data-maxlengthmessage="Maximum 3 characters" maxlength="3" value="" data-flexcontrol="integer-starrating" data-flex-min="1" data-flex-max="10" data-flex-minlabel="1"
                data-flex-maxlabel="10" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="DOUBLE(2,0)">
            </div>
          </div>
          <div class="ff-item-row" style="display: none;">
            <div class="ff-col-1 ff-label-col"><label vatt="REFERENCE" for="inputCase.OwnerId" class="ff-label" id="lblCaseOwnerId">Owner</label></div>
            <div class="ff-col-2 ff-field-col"><input type="hidden" id="Case.OwnerId" vatt="REFERENCE" readonly="readonly" data-vatt="REFERENCE" value="0054M000004jgJGQAY"><input type="textbox" id="inputCase.OwnerId" title="Lookup" placeholder=""
                name="inputCase.OwnerId" class="ff-input-type ff-type-text lookup-link ll-readonly" readonly="readonly" vatt="REFERENCE" value="" data-lobj="Group,User" data-robj="" data-requiredmessage="required" data-isupsert="false"
                data-ishidden="true" data-vatt="REFERENCE"></div>
          </div>
          <div class="ff-item-row" style="display: none;">
            <div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Case.Subject" class="ff-label" id="lblCaseSubject">Subject</label></div>
            <div class="ff-col-2 ff-field-col"><input type="textbox" id="Case.Subject" placeholder="" aria-placeholder="" name="Case.Subject" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 255 characters"
                maxlength="255" data-validatefieldtype="" value="" data-requiredmessage="required" data-isupsert="false" data-ishidden="true" readonly="readonly" data-vatt="STRING" data-rules="1"></div>
          </div>
          <div class="ff-item-row" style="display: none;">
            <div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Case.Salesforce_Case_Number__c" class="ff-label" id="lblCaseSalesforce_Case_Number__c">Salesforce Case Number</label></div>
            <div class="ff-col-2 ff-field-col"><input type="textbox" id="Case.Salesforce_Case_Number__c" placeholder="" aria-placeholder="" name="Case.Salesforce_Case_Number__c" vatt="STRING" class="ff-input-type ff-type-text"
                data-maxlengthmessage="Maximum 15 characters" maxlength="15" data-validatefieldtype="" value="" data-requiredmessage="required" data-isupsert="false" data-ishidden="true" readonly="readonly" data-vatt="STRING"></div>
          </div>
          <div class="ff-item-row" style="display: none;">
            <div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Case.Case_Owner_Name__c" class="ff-label" id="lblCaseCase_Owner_Name__c">Case Owner Name</label></div>
            <div class="ff-col-2 ff-field-col"><input type="textbox" id="Case.Case_Owner_Name__c" placeholder="" aria-placeholder="" name="Case.Case_Owner_Name__c" vatt="STRING" class="ff-input-type ff-type-text"
                data-maxlengthmessage="Maximum 255 characters" maxlength="255" data-validatefieldtype="" value="" data-requiredmessage="required" data-isupsert="false" data-ishidden="true" data-vatt="STRING"></div>
          </div>
          <div class="ff-item-row" style="display: none;">
            <div class="ff-col-1 ff-label-col"><label vatt="REFERENCE" for="inputCase.BusinessHoursId" class="ff-label" id="lblCaseBusinessHoursId">Business Hours</label><span class="requiredSpan ff-required-mark">*</span></div>
            <div class="ff-col-2 ff-field-col"><input type="hidden" id="Case.BusinessHoursId" vatt="REFERENCE" readonly="readonly" data-vatt="REFERENCE" value="01m61000000EKh1AAG"><input type="textbox" id="inputCase.BusinessHoursId" title="Lookup"
                placeholder="" name="inputCase.BusinessHoursId" class="ff-input-type ff-type-text lookup-link ll-readonly" readonly="readonly" vatt="REFERENCE" value="" data-lobj="BusinessHours" data-robj="" data-requiredmessage="required"
                data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="true" data-vatt="REFERENCE"></div>
          </div>
          <div class="ff-item-row" style="display: none;">
            <div class="ff-col-1 ff-label-col"><label vatt="BOOLEAN" for="Case.Received_from_Formstack__c" class="ff-label" id="lblCaseReceived_from_Formstack__c">Received from Formstack</label></div>
            <div class="ff-col-2 ff-field-col"><input type="checkbox" id="Case.Received_from_Formstack__c" name="Case.Received_from_Formstack__c" vatt="BOOLEAN" class="ff-checkbox" data-requiredmessage="required" data-isupsert="false"
                data-ishidden="true" data-vatt="BOOLEAN" data-rules="2" value="on"></div>
          </div>
        </div>
      </div>
      <div class="ff-footer-group">
        <div class="ff-item-row ff-footer-row">
          <div class="ff-submit-btn">
            <div class="footnoteDiv"><span class="requiredSpan  ff-footnote ff-required-mark">*</span><label class="ff-footnote-label ff-label">- required</label></div>
            <div class="btnDiv"><input type="button" class="sectionHeader ff-btn-submit" id="btnsubmit" value="Send" data-btnmessage="Thank you for your submission!" data-btnurl=""></div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <iframe id="ffIframe" name="ffIframe" style="display:none"></iframe>
  <div id="dialog">
  </div>
  <div id="ffLookupDialog" style="overflow:hidden">
  </div>
  <input id="selectedId" type="hidden">
</form>

Text Content

Thank you for taking the time to tell us how we did assisting you with case
00770536 : PROD 11-12 -- FW: Payor - MTI

On a scale of 1 to 10, with 1 being the worst and 10 being awesome, please rate
this experience with Ruth Shields.
Star Rating*
11010
Owner

Subject

Salesforce Case Number

Case Owner Name

Business Hours*

Received from Formstack

*- required