Emergency Assistance Request
None
[]
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'code': '100 lbs to 200 lbs'}, {'name': '200 lbs or more', 'code': '200 lbs or more'}], 'mergePolicy': 'esriMPTDefaultValue', 'splitPolicy': 'esriSPTDefaultValue'}}, {'name': 'EMAIL', 'type': 'esriFieldTypeString', 'alias': 'Email Address', 'length': 100, 'domain': None}, {'name': 'PRIMPHONE', 'type': 'esriFieldTypeString', 'alias': 'Primary Phone Number', 'length': 20, 'domain': None}, {'name': 'SECPHONE', 'type': 'esriFieldTypeString', 'alias': 'Secondary Phone Number', 'length': 20, 'domain': None}, {'name': 'PHYSNAME', 'type': 'esriFieldTypeString', 'alias': 'Physician Name', 'length': 100, 'domain': None}, {'name': 'PHYSFACNAME', 'type': 'esriFieldTypeString', 'alias': 'Physician Facility Name', 'length': 50, 'domain': None}, {'name': 'POCNAME', 'type': 'esriFieldTypeString', 'alias': 'Name of Person Providing the Information', 'length': 100, 'domain': None}, {'name': 'ICENAME', 'type': 'esriFieldTypeString', 'alias': 'Emergency Contact Name', 'length': 100, 'domain': None}, {'name': 'ICERELATION', 'type': 'esriFieldTypeString', 'alias': 'Emergency Contact Relation', 'length': 20, 'domain': None}, {'name': 'ICEPRIMPHONE', 'type': 'esriFieldTypeString', 'alias': 'Emergency Contact Primary Phone', 'length': 20, 'domain': None}, {'name': 'ICESECPHONE', 'type': 'esriFieldTypeString', 'alias': 'Emergency Contact Secondary Phone', 'length': 20, 'domain': None}, {'name': 'ICEEMAIL', 'type': 'esriFieldTypeString', 'alias': 'Emergency Contact Email', 'length': 100, 'domain': None}, {'name': 'OXYGEN', 'type': 'esriFieldTypeString', 'alias': 'Does this individual require oxygen?', 'length': 5, 'domain': {'type': 'codedValue', 'name': 'YesNo', 'description': 'A yes/no indicator', 'codedValues': [{'name': 'Yes', 'code': 'Yes'}, {'name': 'No', 'code': 'No'}], 'mergePolicy': 'esriMPTDefaultValue', 'splitPolicy': 'esriSPTDefaultValue'}}, {'name': 'WHEELCHAIR', 'type': 'esriFieldTypeString', 'alias': 'Does the individual require the use of a wheelchair?', 'length': 5, 'domain': {'type': 'codedValue', 'name': 'YesNo', 'description': 'A yes/no indicator', 'codedValues': [{'name': 'Yes', 'code': 'Yes'}, {'name': 'No', 'code': 'No'}], 'mergePolicy': 'esriMPTDefaultValue', 'splitPolicy': 'esriSPTDefaultValue'}}, {'name': 'HOSPICE', 'type': 'esriFieldTypeString', 'alias': 'Does the individual receive hospice care?', 'length': 5, 'domain': {'type': 'codedValue', 'name': 'YesNo', 'description': 'A yes/no indicator', 'codedValues': [{'name': 'Yes', 'code': 'Yes'}, {'name': 'No', 'code': 'No'}], 'mergePolicy': 'esriMPTDefaultValue', 'splitPolicy': 'esriSPTDefaultValue'}}, {'name': 'DIALYSIS', 'type': 'esriFieldTypeString', 'alias': 'Does the individual receive dialysis treatment?', 'length': 5, 'domain': {'type': 'codedValue', 'name': 'YesNo', 'description': 'A yes/no indicator', 'codedValues': [{'name': 'Yes', 'code': 'Yes'}, {'name': 'No', 'code': 'No'}], 'mergePolicy': 'esriMPTDefaultValue', 'splitPolicy': 'esriSPTDefaultValue'}}, {'name': 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If the pet is not a dog or cat, please describe the pet in the comment section below', 'domain': None}, {'name': 'HEALTHCOMMENT', 'type': 'esriFieldTypeString', 'alias': 'Describe any additional health issues', 'length': 3000, 'domain': None}, {'name': 'MOBILITYCOMMENT', 'type': 'esriFieldTypeString', 'alias': 'Describe any mobility issues', 'length': 3000, 'domain': None}, {'name': 'CASEMGRNAME', 'type': 'esriFieldTypeString', 'alias': 'Name of Case Manager or Home Nurse', 'length': 100, 'domain': None}, {'name': 'CASEMGRAGENCY', 'type': 'esriFieldTypeString', 'alias': 'Agency Name of Case Manager or Home Nurse', 'length': 100, 'domain': None}, {'name': 'ADDCOMMENT', 'type': 'esriFieldTypeString', 'alias': 'Include any additional comments and considerations', 'length': 3000, 'domain': None}, {'name': 'RECDT', 'type': 'esriFieldTypeDate', 'alias': 'Date Received', 'length': 8, 'domain': None}, {'name': 'STAFFNAME', 'type': 'esriFieldTypeString', 'alias': 'Name of Staff Recording Information', 'length': 100, 'domain': None}, {'name': 'STAFFCOMMENT', 'type': 'esriFieldTypeString', 'alias': 'Internal Comments', 'length': 3000, 'domain': None}, {'name': 'VERIFYSTAFFNAME', 'type': 'esriFieldTypeString', 'alias': 'Name of Staff Verifying Information', 'length': 100, 'domain': None}, {'name': 'VERIFYDT', 'type': 'esriFieldTypeDate', 'alias': 'Date Verified', 'length': 8, 'domain': None}, {'name': 'STATUS', 'type': 'esriFieldTypeString', 'alias': 'Status', 'length': 20, 'domain': {'type': 'codedValue', 'name': 'eaStatus', 'description': 'Emergency Assistance request status', 'codedValues': [{'name': 'Submitted', 'code': 'Submitted'}, {'name': 'Verified', 'code': 'Verified'}, {'name': 'Expired', 'code': 'Expired'}], 'mergePolicy': 'esriMPTDefaultValue', 'splitPolicy': 'esriSPTDefaultValue'}}, {'name': 'SHAPE', 'type': 'esriFieldTypeGeometry', 'alias': 'SHAPE', 'domain': None}, {'name': 'CREATEDON', 'type': 'esriFieldTypeDate', 'alias': 'CREATEDON', 'length': 8, 'domain': None}]
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[]
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