"RTW Screen 1"
Bootstrap 4.1.1 Snippet by kbrao007

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<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/js/bootstrap.min.js"></script> <script src="//cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script> <!------ Include the above in your HEAD tag ----------> <!DOCTYPE html> <script src="chrome-extension://ljdobmomdgdljniojadhoplhkpialdid/page/prompt.js"></script><script src="chrome-extension://ljdobmomdgdljniojadhoplhkpialdid/page/runScript.js"></script><head> <meta charset="utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no"> <meta name="description" content=""> <meta name="author" content=""> <link rel="icon" href="../../../../favicon.ico"> <title>Narrow Jumbotron Template for Bootstrap</title> <!-- Bootstrap core CSS --> <link href="../../css/editor.css" rel="stylesheet"> <!-- Custom styles for this template --> <link href="narrow-jumbotron.css" rel="stylesheet"> </head> <body> <div class="container"> <div class="header clearfix" style="height: 706px;"> <nav> <ul class="nav nav-pills float-right"> <li class="nav-item"> </li> <li class="nav-item"> </li> <li class="nav-item"> </li> </ul> </nav> <h3 class="text-muted">Return to Work Request<div class="container" style=""></div></h3> <div class="form-group" style=""><label><b>Name</b></label><input type="text" class="form-control"></div><div class="form-group" style=""><label><b>Title</b></label><input type="text" class="form-control"></div><div class="form-group" style=""></div><p style="height: 50px;"><h3 style="">Health Questions<div class="container" style=""></div></h3><br><p></p><p></p></p><p>Did you have a running Fever in the last 14 Days?</p><label class="checkbox" style="margin-right: 30px; margin-bottom: 0px;"><input type="checkbox"> Yes</label><label class="checkbox" style="margin-bottom: 0px;"><input type="checkbox"> No</label><p style="margin-top: 13px;">Has anyone had a running fever in the last 14 days in the family?</p><label class="checkbox" style="margin-right: 30px; margin-bottom: 0px;"><input type="checkbox"> Yes</label><label class="checkbox" style="margin-right: 30px; margin-bottom: 0px;"><input type="checkbox"> No</label><p style="margin-top: 13px;">Did you get in contact with anyone who has been diagnosed with COVID 19 in the last 14 days?</p><label class="checkbox" style="margin-right: 30px; margin-bottom: 0px;"><input type="checkbox"> Yes</label><label class="checkbox" style="margin-right: 30px; margin-bottom: 0px;"><input type="checkbox"> No</label><div class="form-group" style=""></div><button type="button" class="btn btn-primary" style="border-color: rgb(255, 85, 0); margin-top: 0px; margin-right: 0px;">Next</button></div> <div class="row marketing"> </div> </div> <!-- /container --> </body> </html>

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