{"id":12,"date":"2021-08-31T14:07:01","date_gmt":"2021-08-31T18:07:01","guid":{"rendered":"https:\/\/groupesutera.com\/questionnaires\/?page_id=12"},"modified":"2022-01-07T11:22:26","modified_gmt":"2022-01-07T16:22:26","slug":"questionnaire-covid","status":"publish","type":"page","link":"https:\/\/groupesutera.com\/questionnaires\/","title":{"rendered":"Questionnaire COVID"},"content":{"rendered":"<h2 style=\"text-transform: none; text-align: center;\"><span style=\"color: #1a74ce;\">Mesures pr\u00e9ventives chantiers travailleurs covid-19<\/span><\/h2>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/questionnaires\/wp-json\/wp\/v2\/pages\/12' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_52\" class=\"gfield gfield--type-text rouge field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_2_52\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_52'>Alerte<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='* OUI *' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_71\" ><label class='gfield_label gform-field-label' >Vous \u00eates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_71'>\n\t\t\t<li class='gchoice gchoice_2_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Travailleur'  id='choice_2_71_0'    \/>\n\t\t\t\t<label for='choice_2_71_0' id='label_2_71_0' class='gform-field-label gform-field-label--type-inline'>Travailleur<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='Contrema\u00eetre'  id='choice_2_71_1'    \/>\n\t\t\t\t<label for='choice_2_71_1' id='label_2_71_1' class='gform-field-label gform-field-label--type-inline'>Contrema\u00eetre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_71_2'>\n\t\t\t\t<input name='input_71' type='radio' value='Visiteur'  id='choice_2_71_2'    \/>\n\t\t\t\t<label for='choice_2_71_2' id='label_2_71_2' class='gform-field-label gform-field-label--type-inline'>Visiteur<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_11\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><label class='gfield_label gform-field-label' for='input_2_11'># Le NOMBRE de travailleurs de votre \u00e9quipe pr\u00e9sent sur le chantier aujourd&#039;hui<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_79\" ><label class='gfield_label gform-field-label' >Nom du chantier<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_79'>\n\t\t\t<li class='gchoice gchoice_2_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='2104 SHDM 330 Christin'  id='choice_2_79_0'    \/>\n\t\t\t\t<label for='choice_2_79_0' id='label_2_79_0' class='gform-field-label gform-field-label--type-inline'>2104 SHDM 330 Christin<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='2105 H\u00f4pital Charles Lemoyne (cardiologie)'  id='choice_2_79_1'    \/>\n\t\t\t\t<label for='choice_2_79_1' id='label_2_79_1' class='gform-field-label gform-field-label--type-inline'>2105 H\u00f4pital Charles Lemoyne (cardiologie)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_79_2'>\n\t\t\t\t<input name='input_79' type='radio' value='2106 Caserne 26'  id='choice_2_79_2'    \/>\n\t\t\t\t<label for='choice_2_79_2' id='label_2_79_2' class='gform-field-label gform-field-label--type-inline'>2106 Caserne 26<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_79_3'>\n\t\t\t\t<input name='input_79' type='radio' value='2201 Serres Raymond'  id='choice_2_79_3'    \/>\n\t\t\t\t<label for='choice_2_79_3' id='label_2_79_3' class='gform-field-label gform-field-label--type-inline'>2201 Serres Raymond<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_79_4'>\n\t\t\t\t<input name='input_79' type='radio' value='2205 Cosmod\u00f4me'  id='choice_2_79_4'    \/>\n\t\t\t\t<label for='choice_2_79_4' id='label_2_79_4' class='gform-field-label gform-field-label--type-inline'>2204 Cosmod\u00f4me<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_79_5'>\n\t\t\t\t<input name='input_79' type='radio' value='2208habitationsstsandre@formulairessutera.com'  id='choice_2_79_5'    \/>\n\t\t\t\t<label for='choice_2_79_5' id='label_2_79_5' class='gform-field-label gform-field-label--type-inline'>2208 Habitations Saint-Andr\u00e9 (OMHM)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_79_6'>\n\t\t\t\t<input name='input_79' type='radio' value='0000 Si\u00e8ge social'  id='choice_2_79_6'    \/>\n\t\t\t\t<label for='choice_2_79_6' id='label_2_79_6' class='gform-field-label gform-field-label--type-inline'>0000 Si\u00e8ge social<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><br><div style=\"background-color:#1a74ce;color:#ffffff;padding:5px;font-weight:bold;font-size:16px;\">INFORMATIONS<\/div><\/li><li id=\"field_2_80\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_80\" ><label class='gfield_label gform-field-label' for='input_2_80'>Nom de l&#039;entreprise<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_2_80' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_63\" class=\"gfield gfield--type-text gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_63\" ><label class='gfield_label gform-field-label' for='input_2_63'>Votre nom complet<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_2_63' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_67\" class=\"gfield gfield--type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_67\" ><label class='gfield_label gform-field-label' for='input_2_67'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_2_67' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_72\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_72\" ><br><div style=\"background-color:#1a74ce;color:#ffffff;padding:5px;font-weight:bold;font-size:16px;\">QUESTIONNAIRE<\/div><\/li><li id=\"field_2_73\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_73\" ><br><div style=\"background-color:#000000;color:#ffffff;padding:5px;font-weight:bold;font-size:16px;\">Est-ce vous avez un ou plusieurs des sympt\u00f4mes suivants ?<\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><label class='gfield_label gform-field-label' >Fi\u00e8vre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_15'>\n\t\t\t<li class='gchoice gchoice_2_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Oui'  id='choice_2_15_0'    \/>\n\t\t\t\t<label for='choice_2_15_0' id='label_2_15_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Non'  id='choice_2_15_1'    \/>\n\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_53\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\" ><label class='gfield_label gform-field-label' >Toux<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_53'>\n\t\t\t<li class='gchoice gchoice_2_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Oui'  id='choice_2_53_0'    \/>\n\t\t\t\t<label for='choice_2_53_0' id='label_2_53_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='Non'  id='choice_2_53_1'    \/>\n\t\t\t\t<label for='choice_2_53_1' id='label_2_53_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_54\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\" ><label class='gfield_label gform-field-label' >Difficult\u00e9s respiratoires<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_54'>\n\t\t\t<li class='gchoice gchoice_2_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Oui'  id='choice_2_54_0'    \/>\n\t\t\t\t<label for='choice_2_54_0' id='label_2_54_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='Non'  id='choice_2_54_1'    \/>\n\t\t\t\t<label for='choice_2_54_1' id='label_2_54_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_55\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\" ><label class='gfield_label gform-field-label' >Perte soudaine de l\u2019odorat ou du go\u00fbt<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_55'>\n\t\t\t<li class='gchoice gchoice_2_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Oui'  id='choice_2_55_0'    \/>\n\t\t\t\t<label for='choice_2_55_0' id='label_2_55_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='Non'  id='choice_2_55_1'    \/>\n\t\t\t\t<label for='choice_2_55_1' id='label_2_55_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_62\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_62\" ><br><div style=\"background-color:#000000;color:#ffffff;padding:5px;font-weight:bold;font-size:16px;\">Est-ce que l\u2019une des situations suivantes s\u2019applique \u00e0 vous aujourd'hui ?<\/div><\/li><li id=\"field_2_56\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_56\" ><label class='gfield_label gform-field-label' >A voyag\u00e9 \u00e0 l\u2019ext\u00e9rieur du pays au cours des 2 derni\u00e8res semaines ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_56'>\n\t\t\t<li class='gchoice gchoice_2_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='Oui'  id='choice_2_56_0'    \/>\n\t\t\t\t<label for='choice_2_56_0' id='label_2_56_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='Non'  id='choice_2_56_1'    \/>\n\t\t\t\t<label for='choice_2_56_1' id='label_2_56_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_75\" ><label class='gfield_label gform-field-label' >A \u00e9t\u00e9 en contact avec une personne atteinte de la COVID-19 \/ est en attente d\u2019un test de d\u00e9pistage exig\u00e9 par la sant\u00e9 publique\/ est-ce que la sant\u00e9 publique lui a demand\u00e9 de respecter une quarantaine ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_75'>\n\t\t\t<li class='gchoice gchoice_2_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Oui'  id='choice_2_75_0'    \/>\n\t\t\t\t<label for='choice_2_75_0' id='label_2_75_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='Non'  id='choice_2_75_1'    \/>\n\t\t\t\t<label for='choice_2_75_1' id='label_2_75_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_76\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_76\" ><br><div style=\"background-color:#000000;color:#ffffff;padding:5px;font-weight:bold;font-size:16px;\">Est-ce que l'un de ces sympt\u00f4mes s\u2019applique \u00e0 vous aujourd'hui ?<\/div><\/li><li id=\"field_2_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_74\" ><label class='gfield_label gform-field-label' >Fatigue intense inhabituelle sans raison \u00e9vidente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_74'>\n\t\t\t<li class='gchoice gchoice_2_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Oui'  id='choice_2_74_0'    \/>\n\t\t\t\t<label for='choice_2_74_0' id='label_2_74_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='Non'  id='choice_2_74_1'    \/>\n\t\t\t\t<label for='choice_2_74_1' id='label_2_74_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_57\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\" ><label class='gfield_label gform-field-label' >Douleurs musculaires ou courbatures inhabituelles (non li\u00e9es \u00e0 un effort physique)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_57'>\n\t\t\t<li class='gchoice gchoice_2_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Oui'  id='choice_2_57_0'    \/>\n\t\t\t\t<label for='choice_2_57_0' id='label_2_57_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Non'  id='choice_2_57_1'    \/>\n\t\t\t\t<label for='choice_2_57_1' id='label_2_57_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_58\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_58\" ><label class='gfield_label gform-field-label' >Mal de t\u00eate inhabituel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_58'>\n\t\t\t<li class='gchoice gchoice_2_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Oui'  id='choice_2_58_0'    \/>\n\t\t\t\t<label for='choice_2_58_0' id='label_2_58_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='Non'  id='choice_2_58_1'    \/>\n\t\t\t\t<label for='choice_2_58_1' id='label_2_58_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_59\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_59\" ><label class='gfield_label gform-field-label' >Perte d\u2019app\u00e9tit importante<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_59'>\n\t\t\t<li class='gchoice gchoice_2_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Oui'  id='choice_2_59_0'    \/>\n\t\t\t\t<label for='choice_2_59_0' id='label_2_59_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='Non'  id='choice_2_59_1'    \/>\n\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_60\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\" ><label class='gfield_label gform-field-label' >Naus\u00e9es (maux de coeur), vomissements ou diarrh\u00e9e dans les 12 derni\u00e8res heures<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_60'>\n\t\t\t<li class='gchoice gchoice_2_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Oui'  id='choice_2_60_0'    \/>\n\t\t\t\t<label for='choice_2_60_0' id='label_2_60_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Non'  id='choice_2_60_1'    \/>\n\t\t\t\t<label for='choice_2_60_1' id='label_2_60_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_61\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_61\" ><label class='gfield_label gform-field-label' >Mal de gorge sans autre cause \u00e9vidente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_61'>\n\t\t\t<li class='gchoice gchoice_2_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Oui'  id='choice_2_61_0'    \/>\n\t\t\t\t<label for='choice_2_61_0' id='label_2_61_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='Non'  id='choice_2_61_1'    \/>\n\t\t\t\t<label for='choice_2_61_1' id='label_2_61_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_70\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_70\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Engagement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_70.1' id='input_2_70_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_70_1' >Je m'engage \u00e0 prendre les mesures n\u00e9cessaires pour prot\u00e9ger ma sant\u00e9, ma s\u00e9curit\u00e9, et celles de mes coll\u00e8gues de travail. De plus, je m'engage \u00e0 respecter les lignes directrices \u00e9mises dans le VNESST-COVID-19 - Chantiers de construction.<\/label><input type='hidden' name='input_70.2' value='Je m&#039;engage \u00e0 prendre les mesures n\u00e9cessaires pour prot\u00e9ger ma sant\u00e9, ma s\u00e9curit\u00e9, et celles de mes coll\u00e8gues de travail. De plus, je m&#039;engage \u00e0 respecter les lignes directrices \u00e9mises dans le VNESST-COVID-19 - Chantiers de construction.' class='gform_hidden' \/><input type='hidden' name='input_70.3' value='1' class='gform_hidden' \/><\/div><\/li><li id=\"field_2_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\" ><label class='gfield_label gform-field-label' for='input_2_2'>Votre signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_2_2_valid' id='input_2_2_valid' \/><canvas id='input_2_2' width='600' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_2_78\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_78\" ><script type=\"text\/javascript\">\n        jQuery(document).ready(function(){\n            \/* apply only to a input with a class of gf_readonly *\/\n            jQuery(\".gf_readonly input\").attr(\"readonly\",\"readonly\");\n        });\n    <\/script><\/li><li id=\"field_2_33\" class=\"gfield gfield--type-text gfield--width-full gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\" ><label class='gfield_label gform-field-label' for='input_2_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='19 octobre 2026 07h17' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_77\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_77\" ><br><div style=\"background-color:#ffffff;color:#909090;padding:5px;font-size:12px;line-height:14px;\">Note \u00e0 l'employeur : Pour sa propre sant\u00e9 et la s\u00e9curit\u00e9 de ses coll\u00e8gues de travail, si le travailleur a r\u00e9pondu oui \u00e0 l'une des\nquestions, le travailleur doit retourner \u00e0 la maison et composer le 1 877 644-4545 pour obtenir la marche \u00e0 suivre. Les r\u00e9ponses \u00e0\nces questions sont des renseignements de nature confidentielle et l\u2019employeur doit prendre les mesures n\u00e9cessaires pour s\u2019assurer\nde la protection de la confidentialit\u00e9 de ces renseignements.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Envoyer'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJ7XCI3MC4xXCI6XCJhN2U5ZDMxODkyMWE0MDc0YzEwMDQxMTIyMzYxZDc4YlwiLFwiNzAuMlwiOlwiZWM2M2FlOWYxODRlZWM4ZGNmZjY3YjJmNTlkZWFiMmVcIixcIjcwLjNcIjpcImE3ZTlkMzE4OTIxYTQwNzRjMTAwNDExMjIzNjFkNzhiXCJ9IiwiMDRjODg3ZmFjMjY5ZjdkNTFlMTg3NGFlYThlNTMwOWQiXQ==' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/groupesutera.com\/questionnaires\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https:\/\/groupesutera.com\/questionnaires\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"2\", currentPage: \"current_page\", abort: function() { this.preventDefault(); 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