{"id":19595,"date":"2024-08-23T10:34:31","date_gmt":"2024-08-23T08:34:31","guid":{"rendered":"http:\/\/www.wspr.bialystok.pl\/?page_id=19595"},"modified":"2024-08-23T11:44:27","modified_gmt":"2024-08-23T09:44:27","slug":"19595-2","status":"publish","type":"page","link":"https:\/\/www.wspr.bialystok.pl\/?page_id=19595","title":{"rendered":"Formularz zg\u0142aszania zdarze\u0144 niepo\u017c\u0105danych"},"content":{"rendered":"<div id=\"dslc-theme-content\"><div id=\"dslc-theme-content-inner\">\n<div class=\"forminator-ui forminator-custom-form forminator-custom-form-19594 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-19594\" data-uid=\"6ac97a7d2756a\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-19594\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-19594 forminator-design--material  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"19594\"\n\t\t\t\t data-color-option=\"default\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6ac97a7d2756a\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-19594--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-19594--page-0-label\"\n\t\t\t\tdata-step=\"0\"\n\t\t\t\tdata-label=\"Zako\u0144cz\"\n\t\t\t\tdata-actual-label=\"Strona 1\"\n\t\t\t\tdata-name=\"page-break-1\"\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6ac97a7d2756a\" id=\"forminator-field-name-1_6ac97a7d2756a-label\" class=\"forminator-label\">Imi\u0119 i Nazwisko<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"Na przyk\u0142ad: Jan Kowalski\" id=\"forminator-field-name-1_6ac97a7d2756a\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6ac97a7d2756a\" id=\"forminator-field-email-1_6ac97a7d2756a-label\" class=\"forminator-label\">Adres e-mail<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"Na przyk\u0142ad: jan@kowalski.com\" id=\"forminator-field-email-1_6ac97a7d2756a\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6ac97a7d2756a\" id=\"forminator-field-phone-1_6ac97a7d2756a-label\" class=\"forminator-label\">Numer telefonu<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"Przyk\u0142ad: +48 300 400 5000\" id=\"forminator-field-phone-1_6ac97a7d2756a\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-19594--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-19594--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"Strona  1\"\n\t\t\t\tdata-actual-label=\"Strona 2\"\n\t\t\t\tdata-name=\"page-break-2\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6ac97a7d2756a\" id=\"forminator-field-date-1-picker_6ac97a7d2756a-label\" class=\"forminator-label\">Data zdarzenia <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Wybierz dat\u0119\" id=\"forminator-field-date-1-picker_6ac97a7d2756a\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"time-1\" class=\"forminator-field-time forminator-col forminator-col-6 \"><span id=\"forminator-field-time-1_6ac97a7d2756a-label\" class=\"forminator-label\">Czas zdarzenia <span class=\"forminator-required\">*<\/span><\/span><div class=\"forminator-timepicker\" role=\"group\" aria-labelledby=\"forminator-field-time-1_6ac97a7d2756a-label\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-1-hours\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-hours_6ac97a7d2756a\" id=\"forminator-field-time-1-hours_6ac97a7d2756a-label\" class=\"forminator-label\">Godziny<\/label><input type=\"number\" name=\"time-1-hours\" min=\"0\" max=\"23\" placeholder=\"23\" id=\"forminator-field-time-1-hours_6ac97a7d2756a\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-time-1-minutes_6ac97a7d2756a\" id=\"forminator-field-time-1-minutes_6ac97a7d2756a-label\" class=\"forminator-label\">Minut00<\/label><input type=\"number\" min=\"0\" max=\"59\" name=\"time-1-minutes\" placeholder=\"59\" id=\"forminator-field-time-1-minutes_6ac97a7d2756a\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6ac97a7d2756a\" id=\"forminator-field-textarea-1_6ac97a7d2756a-label\" class=\"forminator-label\">Miejsca zdarzenia <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-1\" placeholder=\"Np. WSPR Bia\u0142ystok\" id=\"forminator-field-textarea-1_6ac97a7d2756a\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6ac97a7d2756a\" id=\"forminator-field-textarea-2_6ac97a7d2756a-label\" class=\"forminator-label\">Osoby zaanga\u017cowane w zdarzenie <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-2\" placeholder=\"Np. Adam Kowalski\" id=\"forminator-field-textarea-2_6ac97a7d2756a\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6ac97a7d2756a-label\"><span id=\"forminator-radiogroup-radio-1-6ac97a7d2756a-label\" class=\"forminator-label\">Kategoria zdarzenia niepo\u017c\u0105danego <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6ac97a7d2756a\" class=\"forminator-radio\" title=\"Zdarzenie zwi\u0105zane z leczeniem i opieka nad pacjentem\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6ac97a7d2756a\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Zdarzenie zwi\u0105zane z leczeniem i opieka nad pacjentem<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6ac97a7d2756a\" class=\"forminator-radio\" title=\"Zdarzenia dotycz\u0105ce farmakoterapii\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6ac97a7d2756a\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Zdarzenia dotycz\u0105ce farmakoterapii<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-6ac97a7d2756a\" class=\"forminator-radio\" title=\"Zdarzenia dotycz\u0105ce sprz\u0119tu medycznego\/wyrob\u00f3w medycznych\/wyposa\u017cenia\"><input type=\"radio\" name=\"radio-1\" value=\"Zdarzenia-dotycz\u0105ce-sprz\u0119tu-medycznego-wyrob\u00f3w-medycznych-wyposa\u017cenia\" id=\"forminator-field-radio-1-3-6ac97a7d2756a\" aria-labelledby=\"forminator-field-radio-1-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Zdarzenia dotycz\u0105ce sprz\u0119tu medycznego\/wyrob\u00f3w medycznych\/wyposa\u017cenia<\/span><\/label><label id=\"forminator-field-radio-1-label-4\" for=\"forminator-field-radio-1-4-6ac97a7d2756a\" class=\"forminator-radio\" title=\"Zdarzenia dotycz\u0105ce organizacji pracy i BHP\"><input type=\"radio\" name=\"radio-1\" value=\"Zdarzenia-dotycz\u0105ce-organizacji-pracy-i-BHP\" id=\"forminator-field-radio-1-4-6ac97a7d2756a\" aria-labelledby=\"forminator-field-radio-1-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Zdarzenia dotycz\u0105ce organizacji pracy i BHP<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-19594--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-19594--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"Strona  2\"\n\t\t\t\tdata-actual-label=\"Strona 3\"\n\t\t\t\tdata-name=\"page-break-3\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6ac97a7d2756a\" id=\"forminator-field-textarea-3_6ac97a7d2756a-label\" class=\"forminator-label\">Opis zdarzenia: <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-3\" placeholder=\"prosz\u0119 szczeg\u00f3\u0142owo opisa\u0107 sytuacj\u0119\" id=\"forminator-field-textarea-3_6ac97a7d2756a\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6ac97a7d2756a\" id=\"forminator-field-textarea-4_6ac97a7d2756a-label\" class=\"forminator-label\">Jakie dzia\u0142ania zosta\u0142y podj\u0119te po zdarzeniu? <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6ac97a7d2756a\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-19594--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-19594--page-3-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"3\"\n\t\t\t\tdata-label=\"Strona  3\"\n\t\t\t\tdata-actual-label=\"Strona 4\"\n\t\t\t\tdata-name=\"page-break-4\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6ac97a7d2756a-label\"><span id=\"forminator-radiogroup-radio-2-6ac97a7d2756a-label\" class=\"forminator-label\">Czy zdarzenie spowodowa\u0142o szkod\u0119? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6ac97a7d2756a\" class=\"forminator-radio\" title=\"TAK\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6ac97a7d2756a\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">TAK<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6ac97a7d2756a\" class=\"forminator-radio\" title=\"NIE\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6ac97a7d2756a\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">NIE<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_6ac97a7d2756a\" id=\"forminator-field-textarea-5_6ac97a7d2756a-label\" class=\"forminator-label\">Je\u015bli TAK, prosz\u0119 opisa\u0107 rodzaj i stopie\u0144 szkody<\/label><textarea name=\"textarea-5\" placeholder=\"Opis\" id=\"forminator-field-textarea-5_6ac97a7d2756a\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-19594--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-19594--page-4-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"4\"\n\t\t\t\tdata-label=\"Strona  4\"\n\t\t\t\tdata-actual-label=\"Strona 5\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6ac97a7d2756a\" id=\"forminator-field-textarea-6_6ac97a7d2756a-label\" class=\"forminator-label\">Wnioski i zalecenia:<\/label><textarea name=\"textarea-6\" placeholder=\"Czy zg\u0142aszaj\u0105cy ma jakie\u015b rekomendacje dotycz\u0105ce zapobiegania podobnym zdarzeniom w przysz\u0142o\u015bci?\" id=\"forminator-field-textarea-6_6ac97a7d2756a\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_6ac97a7d2756a\" id=\"forminator-field-textarea-7_6ac97a7d2756a-label\" class=\"forminator-label\">Inne uwagi:<\/label><textarea name=\"textarea-7\" placeholder=\"Dodatkowe informacje lub uwagi dotycz\u0105ce zdarzenia\" id=\"forminator-field-textarea-7_6ac97a7d2756a\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled><span class=\"forminator-button--mask\" aria-label=\"hidden\"><\/span><span class=\"forminator-button--text\">Wy\u015blij wiadomo\u015b\u0107<\/span><\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"046665626f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F19595\" \/><input type=\"hidden\" name=\"form_id\" value=\"19594\"><input type=\"hidden\" name=\"page_id\" value=\"19595\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/www.wspr.bialystok.pl\/?page_id=19595\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:100%\">\n<pre class=\"wp-block-code\"><code>Badanie opinii i do\u015bwiadcze\u0144 pacjent\u00f3w \n\n<a href=\"https:\/\/www.gov.pl\/web\/zdrowie\/ankiety-badania-doswiadczen-i-opinii-pacjenta\">https:\/\/www.gov.pl\/web\/zdrowie\/ankiety-badania-doswiadczen-i-opinii-pacjenta<\/a>\n\n\n\n<\/code><\/pre>\n<\/div>\n<\/div>\n<\/div><\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":28,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-19595","page","type-page","status-publish"],"_links":{"self":[{"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=\/wp\/v2\/pages\/19595","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=\/wp\/v2\/users\/28"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=19595"}],"version-history":[{"count":6,"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=\/wp\/v2\/pages\/19595\/revisions"}],"predecessor-version":[{"id":19608,"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=\/wp\/v2\/pages\/19595\/revisions\/19608"}],"wp:attachment":[{"href":"https:\/\/www.wspr.bialystok.pl\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=19595"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}