{"id":85,"date":"2025-01-31T16:05:05","date_gmt":"2025-01-31T21:05:05","guid":{"rendered":"https:\/\/www.ecdpw.org\/survey\/?page_id=85"},"modified":"2025-01-31T16:34:04","modified_gmt":"2025-01-31T21:34:04","slug":"online-service-request","status":"publish","type":"page","link":"https:\/\/www.ecdpw.org\/survey\/online-service-request\/","title":{"rendered":"Online Service Request"},"content":{"rendered":"<p><div class=\"forminator-ui forminator-custom-form forminator-custom-form-84 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-84\" data-uid=\"69fbd3fc30d8c\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-84\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-84 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=\"84\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69fbd3fc30d8c\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><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_69fbd3fc30d8c\" id=\"forminator-field-name-1_69fbd3fc30d8c-label\" class=\"forminator-label\">Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69fbd3fc30d8c\" id=\"forminator-field-email-1_69fbd3fc30d8c-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69fbd3fc30d8c\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69fbd3fc30d8c\" id=\"forminator-field-phone-1_69fbd3fc30d8c-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69fbd3fc30d8c\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69fbd3fc30d8c\" id=\"forminator-field-text-4_69fbd3fc30d8c-label\" class=\"forminator-label\">Address 1 <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69fbd3fc30d8c\" id=\"forminator-field-text-7_69fbd3fc30d8c-label\" class=\"forminator-label\">Address 2<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69fbd3fc30d8c\" id=\"forminator-field-text-8_69fbd3fc30d8c-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69fbd3fc30d8c\" id=\"forminator-field-text-5_69fbd3fc30d8c-label\" class=\"forminator-label\">State <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69fbd3fc30d8c\" id=\"forminator-field-text-6_69fbd3fc30d8c-label\" class=\"forminator-label\">Zip <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/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-1-69fbd3fc30d8c-label\"><span id=\"forminator-radiogroup-radio-1-69fbd3fc30d8c-label\" class=\"forminator-label\">I want to request (please select) <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Pothole \/ sidewalk repair\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69fbd3fc30d8c\" 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\">Pothole \/ sidewalk repair<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Roadway debris \/ litter removal\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69fbd3fc30d8c\" 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\">Roadway debris \/ litter removal<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Damaged and\/or dead limbs\"><input type=\"radio\" name=\"radio-1\" value=\"Damaged-and-or-dead-limbs\" id=\"forminator-field-radio-1-3-69fbd3fc30d8c\" 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\">Damaged and\/or dead limbs<\/span><\/label><label id=\"forminator-field-radio-1-label-4\" for=\"forminator-field-radio-1-4-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Street or sidewalk blocked\"><input type=\"radio\" name=\"radio-1\" value=\"Street-or-sidewalk-blocked\" id=\"forminator-field-radio-1-4-69fbd3fc30d8c\" 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\">Street or sidewalk blocked<\/span><\/label><label id=\"forminator-field-radio-1-label-5\" for=\"forminator-field-radio-1-5-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Mosquito inspection\"><input type=\"radio\" name=\"radio-1\" value=\"Mosquito-inspection\" id=\"forminator-field-radio-1-5-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-radio-1-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Mosquito inspection<\/span><\/label><label id=\"forminator-field-radio-1-label-6\" for=\"forminator-field-radio-1-6-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Carcass removal\"><input type=\"radio\" name=\"radio-1\" value=\"Carcass-removal\" id=\"forminator-field-radio-1-6-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-radio-1-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Carcass removal<\/span><\/label><label id=\"forminator-field-radio-1-label-7\" for=\"forminator-field-radio-1-7-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Snow \/ ice removal\"><input type=\"radio\" name=\"radio-1\" value=\"Snow---ice-removal\" id=\"forminator-field-radio-1-7-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-radio-1-label-7\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Snow \/ ice removal<\/span><\/label><label id=\"forminator-field-radio-1-label-8\" for=\"forminator-field-radio-1-8-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Interference with a traffic sign or signals\"><input type=\"radio\" name=\"radio-1\" value=\"Interference-with-a-traffic-sign-or-signals\" id=\"forminator-field-radio-1-8-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-radio-1-label-8\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Interference with a traffic sign or signals<\/span><\/label><label id=\"forminator-field-radio-1-label-9\" for=\"forminator-field-radio-1-9-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Traffic signal repair\"><input type=\"radio\" name=\"radio-1\" value=\"Traffic-signal-repair\" id=\"forminator-field-radio-1-9-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-radio-1-label-9\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Traffic signal repair<\/span><\/label><label id=\"forminator-field-radio-1-label-10\" for=\"forminator-field-radio-1-10-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Missing \/ damaged sign repair\"><input type=\"radio\" name=\"radio-1\" value=\"Missing---damaged-sign-repair\" id=\"forminator-field-radio-1-10-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-radio-1-label-10\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Missing \/ damaged sign repair<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69fbd3fc30d8c-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-69fbd3fc30d8c-label\" class=\"forminator-label\">Way of contact <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-1-1-69fbd3fc30d8c-label\" for=\"forminator-field-checkbox-1-1-69fbd3fc30d8c\" class=\"forminator-checkbox\" title=\"Email\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-checkbox-1-1-69fbd3fc30d8c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Email<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69fbd3fc30d8c-label\" for=\"forminator-field-checkbox-1-2-69fbd3fc30d8c\" class=\"forminator-checkbox\" title=\"Phone\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-checkbox-1-2-69fbd3fc30d8c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Phone<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69fbd3fc30d8c-label\" for=\"forminator-field-checkbox-1-3-69fbd3fc30d8c\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Other\" id=\"forminator-field-checkbox-1-3-69fbd3fc30d8c\" aria-labelledby=\"forminator-field-checkbox-1-3-69fbd3fc30d8c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-69fbd3fc30d8c-label\"><span id=\"forminator-radiogroup-radio-2-69fbd3fc30d8c-label\" class=\"forminator-label\">Permission to access property? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-69fbd3fc30d8c\" 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\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69fbd3fc30d8c\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-69fbd3fc30d8c\" 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\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69fbd3fc30d8c\" id=\"forminator-field-text-1_69fbd3fc30d8c-label\" class=\"forminator-label\">Incident Location <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69fbd3fc30d8c\" id=\"forminator-field-text-2_69fbd3fc30d8c-label\" class=\"forminator-label\">Access \/ egress <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"locked gate, dog, etc.\" id=\"forminator-field-text-2_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69fbd3fc30d8c\" id=\"forminator-field-text-3_69fbd3fc30d8c-label\" class=\"forminator-label\">Cross street <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69fbd3fc30d8c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/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_69fbd3fc30d8c\" id=\"forminator-field-textarea-1_69fbd3fc30d8c-label\" class=\"forminator-label\">Comments <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69fbd3fc30d8c\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><span id=\"forminator-field-textarea-1_69fbd3fc30d8c-description\" class=\"forminator-description\"><span data-limit=\"250\" data-type=\"words\" data-editor=\"\">0 \/ 250<\/span><\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"captcha-1\" class=\"forminator-field-captcha forminator-col forminator-col-12 \"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"inline\" data-sitekey=\"6LcEGE8qAAAAABOzxLDsLe9mutNLxU3hNECXP8Nf\" data-size=\"invisible\"><\/div> <\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\"><span>Send Service Request<\/span><span aria-hidden=\"true\"><\/span><\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"204067cb7a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/survey\/wp-json\/wp\/v2\/pages\/85\" \/><input type=\"hidden\" name=\"form_id\" value=\"84\"><input type=\"hidden\" name=\"page_id\" value=\"85\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/www.ecdpw.org\/survey\/online-service-request\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"simple-template","meta":{"footnotes":""},"class_list":["post-85","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/pages\/85","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/comments?post=85"}],"version-history":[{"count":1,"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/pages\/85\/revisions"}],"predecessor-version":[{"id":87,"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/pages\/85\/revisions\/87"}],"wp:attachment":[{"href":"https:\/\/www.ecdpw.org\/survey\/wp-json\/wp\/v2\/media?parent=85"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}