{"id":11,"date":"2026-05-28T20:53:57","date_gmt":"2026-05-28T20:53:57","guid":{"rendered":"https:\/\/www.ameci.cl\/declaracion-salud\/?page_id=11"},"modified":"2026-06-01T17:08:30","modified_gmt":"2026-06-01T17:08:30","slug":"declaracion-de-salud","status":"publish","type":"page","link":"https:\/\/www.ameci.cl\/declaracion-salud\/","title":{"rendered":""},"content":{"rendered":"\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" src=\"https:\/\/www.ameci.cl\/declaracion-salud\/wp-content\/uploads\/2026\/05\/LOGO_AMECI2.png\" alt=\"\"\/><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\" style=\"margin-top:var(--wp--preset--spacing--20);margin-bottom:var(--wp--preset--spacing--20)\"\/>\n\n\n<div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Formulario para declaracion de salud<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='11' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"81de4e2b7e\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/declaracion-salud\/wp-json\/wp\/v2\/pages\/11\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><h1 style=\"text-align: center\"><strong>DECLARACI\u00d3N DE SALUD DEL TRABAJADOR<\/strong><\/h1><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_2\" ><h2 style=\"text-align: left\"><strong>1.- IDENTIFICACI\u00d3N DEL TRABAJADOR<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 45.11%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_7' id='label_ff_3_input_text_7' aria-label=\"Nombre completo:\">Nombre completo:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_3_input_text_7\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_cargo' id='label_ff_3_input_cargo' aria-label=\"Cargo:\">Cargo:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_cargo\" class=\"ff-el-form-control\" data-name=\"input_cargo\" id=\"ff_3_input_cargo\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 54.89%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_mask' id='label_ff_3_input_mask' aria-label=\"Rut:\">Rut:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask\" data-mask=\"99.999.999-*\" class=\"ff-el-form-control\" placeholder=\"99.999.999-9\" data-name=\"input_mask\" id=\"ff_3_input_mask\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_fecha_ingreso' id='label_ff_3_input_fecha_ingreso' aria-label=\"Fecha de ingreso\">Fecha de ingreso<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_fecha_ingreso\" data-mask=\"00\/00\/0000\" class=\"ff-el-form-control\" placeholder=\"dd-mm-aaaa\" data-name=\"input_fecha_ingreso\" id=\"ff_3_input_fecha_ingreso\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_3\" ><h2 style=\"text-align: left\"><strong>2.- ANTECEDENTES MEDICOS: Ha tenido o tiene alg\u00fan s\u00edntoma o enfermedad como las descritas a continuaci\u00f3n<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 88.49%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"1.- Disminuci\u00f3n de visi\u00f3n\">1.- Disminuci\u00f3n de visi\u00f3n<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_1_f0373e417c1d2fe11ae0170a8b6ac2c4'><input  type=\"radio\" name=\"input_1\" data-name=\"input_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_1_f0373e417c1d2fe11ae0170a8b6ac2c4' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_1_81ae3653668c08e7a40a6f8e273a9a05'><input  type=\"radio\" name=\"input_1\" data-name=\"input_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_1_81ae3653668c08e7a40a6f8e273a9a05' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 11.51%;'><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"2.- \u00bfDisminuci\u00f3n de la audici\u00f3n\">2.- \u00bfDisminuci\u00f3n de la audici\u00f3n<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_2_2f4271fc6fad8003023b9ef0206783ac'><input  type=\"radio\" name=\"input_2\" data-name=\"input_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_2_2f4271fc6fad8003023b9ef0206783ac' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_2_b598b39fa25d20789d067d3ac1b86afc'><input  type=\"radio\" name=\"input_2\" data-name=\"input_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_2_b598b39fa25d20789d067d3ac1b86afc' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"3.- Diabetes\">3.- Diabetes<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_3_84ec8fc9b76f59411524108d19174bd5'><input  type=\"radio\" name=\"input_3\" data-name=\"input_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_3_84ec8fc9b76f59411524108d19174bd5' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_3_f6bdae07af2720abf7c828344a7ed36f'><input  type=\"radio\" name=\"input_3\" data-name=\"input_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_3_f6bdae07af2720abf7c828344a7ed36f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"4.- Secuela de accidentes y\/o enfermedades no laborales\">4.- Secuela de accidentes y\/o enfermedades no laborales<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_4_ef68f83af02c287222b9687eda9c30d0'><input  type=\"radio\" name=\"input_4\" data-name=\"input_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_4_ef68f83af02c287222b9687eda9c30d0' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_4_a191e2e22b308db6439e9891c3306cc5'><input  type=\"radio\" name=\"input_4\" data-name=\"input_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_4_a191e2e22b308db6439e9891c3306cc5' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_4' id='label_ff_3_input_texto_4' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_4\" class=\"ff-el-form-control\" data-name=\"input_texto_4\" id=\"ff_3_input_texto_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"5.- Epilepsia\">5.- Epilepsia<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_5_b9b9191ad681e91e015626d5f58b2e7e'><input  type=\"radio\" name=\"input_5\" data-name=\"input_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_5_b9b9191ad681e91e015626d5f58b2e7e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_5_10902275f3445d3242d291b3aff9b0b9'><input  type=\"radio\" name=\"input_5\" data-name=\"input_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_5_10902275f3445d3242d291b3aff9b0b9' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"6.- V\u00e9rtigo\">6.- V\u00e9rtigo<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_6_6618de999de6195d54b7dea60ccfdb2d'><input  type=\"radio\" name=\"input_6\" data-name=\"input_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_6_6618de999de6195d54b7dea60ccfdb2d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_6_183b5acb13711239e6f558959d44e7bb'><input  type=\"radio\" name=\"input_6\" data-name=\"input_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_6_183b5acb13711239e6f558959d44e7bb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"7.- Tumor o c\u00e1ncer\">7.- Tumor o c\u00e1ncer<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_7_cea2de4d4b47fc3ab20509a1dd563f01'><input  type=\"radio\" name=\"input_7\" data-name=\"input_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_7_cea2de4d4b47fc3ab20509a1dd563f01' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_7_730f6425f46fa2104724f3301afde476'><input  type=\"radio\" name=\"input_7\" data-name=\"input_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_7_730f6425f46fa2104724f3301afde476' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"8.- Antecedentes cardiovasculares\">8.- Antecedentes cardiovasculares<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_8_7a032916b2984c04a11e5ec878929f04'><input  type=\"radio\" name=\"input_8\" data-name=\"input_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_8_7a032916b2984c04a11e5ec878929f04' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_8_d2282fae5a21a3a0ea9b2cb081ed67ee'><input  type=\"radio\" name=\"input_8\" data-name=\"input_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_8_d2282fae5a21a3a0ea9b2cb081ed67ee' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_8' id='label_ff_3_input_texto_8' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_8\" class=\"ff-el-form-control\" data-name=\"input_texto_8\" id=\"ff_3_input_texto_8\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"9.- Antecedentes de tipo respiratorio\">9.- Antecedentes de tipo respiratorio<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_9_dcf74bcd811958a87c2c356989d5f547'><input  type=\"radio\" name=\"input_9\" data-name=\"input_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_9_dcf74bcd811958a87c2c356989d5f547' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_9_643981c3248c2d8dd5d7c2c094bfded3'><input  type=\"radio\" name=\"input_9\" data-name=\"input_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_9_643981c3248c2d8dd5d7c2c094bfded3' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_9' id='label_ff_3_input_texto_9' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_9\" class=\"ff-el-form-control\" data-name=\"input_texto_9\" id=\"ff_3_input_texto_9\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"10.- \u00bfConsume alg\u00fan medicamento?\">10.- \u00bfConsume alg\u00fan medicamento?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_10_ca738a40aef5546a55cb5399b8fbfac1'><input  type=\"radio\" name=\"input_10\" data-name=\"input_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_10_ca738a40aef5546a55cb5399b8fbfac1' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_10_eb31677fb137d75cb9487c86a3361ce7'><input  type=\"radio\" name=\"input_10\" data-name=\"input_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_10_eb31677fb137d75cb9487c86a3361ce7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_10' id='label_ff_3_input_texto_10' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_10\" class=\"ff-el-form-control\" data-name=\"input_texto_10\" id=\"ff_3_input_texto_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"11.- \u00bfPosee antecedentes de tipo al\u00e9rgico?\">11.- \u00bfPosee antecedentes de tipo al\u00e9rgico?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_11_f609bd8294593343d3537358f62b0f35'><input  type=\"radio\" name=\"input_11\" data-name=\"input_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_11_f609bd8294593343d3537358f62b0f35' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_11_0054fb40f7dbca81999607fc2915acaf'><input  type=\"radio\" name=\"input_11\" data-name=\"input_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_11_0054fb40f7dbca81999607fc2915acaf' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_11' id='label_ff_3_input_texto_11' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_11\" class=\"ff-el-form-control\" data-name=\"input_texto_11\" id=\"ff_3_input_texto_11\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"12.- \u00bfHa sido alguna vez operado?\">12.- \u00bfHa sido alguna vez operado?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_fcf6bdef61d3a4e871086bfae6f276a4'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_fcf6bdef61d3a4e871086bfae6f276a4' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_bf2c066b0f58532ae1afd3ccd6cfcdc4'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_bf2c066b0f58532ae1afd3ccd6cfcdc4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' id='label_ff_3_input_text' aria-label=\"Se\u00f1ale\">Se\u00f1ale<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"13.- \u00bfSufre de alguna enfermedad cr\u00f3nica? (Lumbago, Tendinitis, etc.)\">13.- \u00bfSufre de alguna enfermedad cr\u00f3nica? (Lumbago, Tendinitis, etc.)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_be26654b434bb5d912fc4c35a18d0b91'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_2_be26654b434bb5d912fc4c35a18d0b91' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_7d031b62c7f6e99505ee96177302af64'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_2_7d031b62c7f6e99505ee96177302af64' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_2' id='label_ff_3_input_text_2' aria-label=\"\u00bfCu\u00e1l?\">\u00bfCu\u00e1l?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_3_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"14.- \u00bfSufre de presi\u00f3n arterial? (Hipertensi\u00f3n, etc.)\">14.- \u00bfSufre de presi\u00f3n arterial? (Hipertensi\u00f3n, etc.)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_28af069f21136b74065b195e14330e0e'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_1_28af069f21136b74065b195e14330e0e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_d3099be99268342330d9be53c62f1749'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_1_d3099be99268342330d9be53c62f1749' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_1' id='label_ff_3_input_text_1' aria-label=\"Se\u00f1ale\">Se\u00f1ale<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"15.- \u00bfConsume o ha consumido Alcohol?\">15.- \u00bfConsume o ha consumido Alcohol?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_b494a682cbed6f855321cb02c7c29b0c'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_5_b494a682cbed6f855321cb02c7c29b0c' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_56c39e516b62d3ab7be297af4eef4496'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_5_56c39e516b62d3ab7be297af4eef4496' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfCon que frecuencia?\">\u00bfCon que frecuencia?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_80742b502ff7c977bbcb9508b7b81f41'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Todos los dias\"  id='input_radio_7_80742b502ff7c977bbcb9508b7b81f41' aria-label='Todos los dias' aria-invalid='false' aria-required=true> <span>Todos los dias<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_7a660c405ce781a9b0cd03cfd6a8bbc6'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"En ocasiones\"  id='input_radio_7_7a660c405ce781a9b0cd03cfd6a8bbc6' aria-label='En ocasiones' aria-invalid='false' aria-required=true> <span>En ocasiones<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_4f56c7efa1b86a6e9cf2296b5600a7d3'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Rara vez\"  id='input_radio_7_4f56c7efa1b86a6e9cf2296b5600a7d3' aria-label='Rara vez' aria-invalid='false' aria-required=true> <span>Rara vez<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfCuanto consume?\">\u00bfCuanto consume?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_c5a2d00335819ca8801173efde45bb8e'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mas de 3 vasos\"  id='input_radio_8_c5a2d00335819ca8801173efde45bb8e' aria-label='Mas de 3 vasos' aria-invalid='false' aria-required=true> <span>Mas de 3 vasos<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_7b59dc39e5e73c8ba4ba2db84c03bf33'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"De 2 a 3 vasos\"  id='input_radio_8_7b59dc39e5e73c8ba4ba2db84c03bf33' aria-label='De 2 a 3 vasos' aria-invalid='false' aria-required=true> <span>De 2 a 3 vasos<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_c32a2950ac500c40eb6d05cec7f420a2'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Solo 1 vaso\"  id='input_radio_8_c32a2950ac500c40eb6d05cec7f420a2' aria-label='Solo 1 vaso' aria-invalid='false' aria-required=true> <span>Solo 1 vaso<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"16.- \u00bfEs usted fumador?\">16.- \u00bfEs usted fumador?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_15855b31bad7eb6b2ab50f0d2db6aad7'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_4_15855b31bad7eb6b2ab50f0d2db6aad7' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_fd0242ef0d44298d406c5cf7bc8a18bb'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_4_fd0242ef0d44298d406c5cf7bc8a18bb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_4' id='label_ff_3_input_text_4' aria-label=\"\u00bfCuanto fuma al dia?\">\u00bfCuanto fuma al dia?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_3_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"17.- \u00bfConsume o ha consumido drogas (marihuana, coca\u00edna, pasta base, etc.)?\">17.- \u00bfConsume o ha consumido drogas (marihuana, coca\u00edna, pasta base, etc.)?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_72b2084c89dbddee01b05b30a5ecf8eb'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_3_72b2084c89dbddee01b05b30a5ecf8eb' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_8e906662447cdf5c900b3ce7391d0346'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_3_8e906662447cdf5c900b3ce7391d0346' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_3' id='label_ff_3_input_text_3' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_3_input_text_3\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"18.- \u00bfUsted Ronca?\">18.- \u00bfUsted Ronca?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_ronca_f4f174cc114fd8cbb4add62c402d90f5'><input  type=\"radio\" name=\"input_ronca\" data-name=\"input_ronca\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_ronca_f4f174cc114fd8cbb4add62c402d90f5' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_ronca_4d806c9aa1cfb5976068c434593e9580'><input  type=\"radio\" name=\"input_ronca\" data-name=\"input_ronca\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_ronca_4d806c9aa1cfb5976068c434593e9580' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"19.- \u00bfRealiza Actividad F\u00edsica?\">19.- \u00bfRealiza Actividad F\u00edsica?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_act_fisica_1cb65ebcd2b1fb80bdd7f78d1407aaaf'><input  type=\"radio\" name=\"input_act_fisica\" data-name=\"input_act_fisica\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_act_fisica_1cb65ebcd2b1fb80bdd7f78d1407aaaf' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_act_fisica_7596df623000d298d84c04cada945175'><input  type=\"radio\" name=\"input_act_fisica\" data-name=\"input_act_fisica\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_act_fisica_7596df623000d298d84c04cada945175' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_4\" ><h2 style=\"text-align: left\"><strong>3.- PATOLOG\u00cdAS DE ORIGEN LABORAL<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sido evaluado por enfermedad profesional?\">\u00bfHa sido evaluado por enfermedad profesional?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsepep_bdd8df9154dd70f5649e65773803fed8'><input  type=\"radio\" name=\"input_hsepep\" data-name=\"input_hsepep\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsepep_bdd8df9154dd70f5649e65773803fed8' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsepep_3f70cdebea89729041fe414105929b56'><input  type=\"radio\" name=\"input_hsepep\" data-name=\"input_hsepep\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hsepep_3f70cdebea89729041fe414105929b56' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_anio' id='label_ff_3_input_anio' aria-label=\"A\u00f1o\">A\u00f1o<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_anio\" class=\"ff-el-form-control\" data-name=\"input_anio\" id=\"ff_3_input_anio\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_empresa' id='label_ff_3_input_empresa' aria-label=\"Empresa\">Empresa<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_empresa\" class=\"ff-el-form-control\" data-name=\"input_empresa\" id=\"ff_3_input_empresa\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_22\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sufrido alg\u00fan accidente?\">\u00bfHa sufrido alg\u00fan accidente?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsac_35286330cb1ffad24625473efe8944a7'><input  type=\"radio\" name=\"input_hsac\" data-name=\"input_hsac\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsac_35286330cb1ffad24625473efe8944a7' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsac_c164e1f6a43f58216a73afe34a4edef7'><input  type=\"radio\" name=\"input_hsac\" data-name=\"input_hsac\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hsac_c164e1f6a43f58216a73afe34a4edef7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_cual' id='label_ff_3_input_cual' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_cual\" class=\"ff-el-form-control\" data-name=\"input_cual\" id=\"ff_3_input_cual\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_mlesiones' id='label_ff_3_input_mlesiones' aria-label=\"Mencione Lesiones\">Mencione Lesiones<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mlesiones\" class=\"ff-el-form-control\" data-name=\"input_mlesiones\" id=\"ff_3_input_mlesiones\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_23\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group has-conditions ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfEl accidente fue dentro del trabajo?\">\u00bfEl accidente fue dentro del trabajo?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_1c37799a80016c018e54a79ac1a02353'><input  type=\"radio\" name=\"input_eafddt\" data-name=\"input_eafddt\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_eafddt_1c37799a80016c018e54a79ac1a02353' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_9955ceb67d4db89937c1052013fe4085'><input  type=\"radio\" name=\"input_eafddt\" data-name=\"input_eafddt\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_eafddt_9955ceb67d4db89937c1052013fe4085' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_anio_eafddt' id='label_ff_3_input_anio_eafddt' aria-label=\"A\u00f1o\">A\u00f1o<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_anio_eafddt\" class=\"ff-el-form-control\" data-name=\"input_anio_eafddt\" id=\"ff_3_input_anio_eafddt\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_eafddt_empresa' id='label_ff_3_input_eafddt_empresa' aria-label=\"Empresa\">Empresa<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_eafddt_empresa\" class=\"ff-el-form-control\" data-name=\"input_eafddt_empresa\" id=\"ff_3_input_eafddt_empresa\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_24\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.55%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa trabajado anteriormente expuesto a agentes de riesgo?\">\u00bfHa trabajado anteriormente expuesto a agentes de riesgo?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_htaeaadr_4154794b7a1c9f93eb96bbe76c7b61fe'><input  type=\"radio\" name=\"input_htaeaadr\" data-name=\"input_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_htaeaadr_4154794b7a1c9f93eb96bbe76c7b61fe' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_htaeaadr_ed3b9a38230f058d900e63d30254dc98'><input  type=\"radio\" name=\"input_htaeaadr\" data-name=\"input_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_htaeaadr_ed3b9a38230f058d900e63d30254dc98' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.45%;'><div class='ff-el-group has-conditions ff_list_2col'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Selecciona la\/las opci\u00f3n\/es\">Selecciona la\/las opci\u00f3n\/es<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_f38995efdb86d4f0876db9bbbfd27dec'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ruido\"  id='checkbox_htaeaadr_f38995efdb86d4f0876db9bbbfd27dec' aria-label='Ruido' aria-invalid='false' aria-required=true> <span>Ruido<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_d844f04723eb53b3d0ad238df1340fb8'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Polvo (S\u00edlice, madera, cemento, etc.)\"  id='checkbox_htaeaadr_d844f04723eb53b3d0ad238df1340fb8' aria-label='Polvo (S\u00edlice, madera, cemento, etc.)' aria-invalid='false' aria-required=true> <span>Polvo (S\u00edlice, madera, cemento, etc.)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_0ab18838c7e6f9a493f21dbdae69bf95'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sustancias qu\u00edmicas\"  id='checkbox_htaeaadr_0ab18838c7e6f9a493f21dbdae69bf95' aria-label='Sustancias qu\u00edmicas' aria-invalid='false' aria-required=true> <span>Sustancias qu\u00edmicas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_3969eaa80173610904f500baa6b86ced'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Vibraciones\"  id='checkbox_htaeaadr_3969eaa80173610904f500baa6b86ced' aria-label='Vibraciones' aria-invalid='false' aria-required=true> <span>Vibraciones<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_8e5be0344335bcc8ab58686cea4922b9'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Radiaci\u00f3n UV\"  id='checkbox_htaeaadr_8e5be0344335bcc8ab58686cea4922b9' aria-label='Radiaci\u00f3n UV' aria-invalid='false' aria-required=true> <span>Radiaci\u00f3n UV<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_776dd04663054e66ca295498a691cbab'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Trabajo en altura geogr\u00e1fica\"  id='checkbox_htaeaadr_776dd04663054e66ca295498a691cbab' aria-label='Trabajo en altura geogr\u00e1fica' aria-invalid='false' aria-required=true> <span>Trabajo en altura geogr\u00e1fica<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_a9ddca29f757665d62fa7067d796f22b'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Otro\"  id='checkbox_htaeaadr_a9ddca29f757665d62fa7067d796f22b' aria-label='Otro' aria-invalid='false' aria-required=true> <span>Otro<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_htaeaadr' id='label_ff_3_input_texto_htaeaadr' aria-label=\"\u00bfCuales?\">\u00bfCuales?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_htaeaadr\" class=\"ff-el-form-control\" data-name=\"input_texto_htaeaadr\" id=\"ff_3_input_texto_htaeaadr\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_25\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa participado en alg\u00fan programa de vigilancia de salud ocupacional?\">\u00bfHa participado en alg\u00fan programa de vigilancia de salud ocupacional?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hpeapdvdso_1589c2460fdb6e44567cdb72f6070b56'><input  type=\"radio\" name=\"input_hpeapdvdso\" data-name=\"input_hpeapdvdso\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hpeapdvdso_1589c2460fdb6e44567cdb72f6070b56' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hpeapdvdso_c9fe4ee95f6b585c01f7e2bb3e1256b0'><input  type=\"radio\" name=\"input_hpeapdvdso\" data-name=\"input_hpeapdvdso\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hpeapdvdso_c9fe4ee95f6b585c01f7e2bb3e1256b0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_anio_eafddt_2' id='label_ff_3_input_anio_eafddt_2' aria-label=\"\u00bfCu\u00e1l?\">\u00bfCu\u00e1l?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_anio_eafddt_2\" class=\"ff-el-form-control\" data-name=\"input_anio_eafddt_2\" id=\"ff_3_input_anio_eafddt_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_26\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfLe han diagnosticado alguna enfermedad relacionada con su trabajo?\">\u00bfLe han diagnosticado alguna enfermedad relacionada con su trabajo?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_3_618d362f8bc69ac810d01ec34ed2b508'><input  type=\"radio\" name=\"input_eafddt_3\" data-name=\"input_eafddt_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_eafddt_3_618d362f8bc69ac810d01ec34ed2b508' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_3_f13273d56a7ce9a6c51b5a34d44aaeba'><input  type=\"radio\" name=\"input_eafddt_3\" data-name=\"input_eafddt_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_eafddt_3_f13273d56a7ce9a6c51b5a34d44aaeba' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_cual_lhdaercst' id='label_ff_3_input_cual_lhdaercst' aria-label=\"\u00bfCu\u00e1l?\">\u00bfCu\u00e1l?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_cual_lhdaercst\" class=\"ff-el-form-control\" data-name=\"input_cual_lhdaercst\" id=\"ff_3_input_cual_lhdaercst\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_27\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.96%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfPosee alguna restricci\u00f3n m\u00e9dica para realizar actividades laborales?\">\u00bfPosee alguna restricci\u00f3n m\u00e9dica para realizar actividades laborales?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_parmpral_8555bc0558517e76f5da8f3ca629a340'><input  type=\"radio\" name=\"input_parmpral\" data-name=\"input_parmpral\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_parmpral_8555bc0558517e76f5da8f3ca629a340' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_parmpral_fe1cbaf5e95e43d3e6fbee2c85efe7fb'><input  type=\"radio\" name=\"input_parmpral\" data-name=\"input_parmpral\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_parmpral_fe1cbaf5e95e43d3e6fbee2c85efe7fb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.04%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_indique_parmpral' id='label_ff_3_input_indique_parmpral' aria-label=\"Indique\">Indique<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_indique_parmpral\" class=\"ff-el-form-control\" data-name=\"input_indique_parmpral\" id=\"ff_3_input_indique_parmpral\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_28\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.69%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sufrido anteriormente alg\u00fan accidente del trabajo o enfermedad profesional calificada por el organismo administrador?\">\u00bfHa sufrido anteriormente alg\u00fan accidente del trabajo o enfermedad profesional calificada por el organismo administrador?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsaaadtoepcpeoa_c6a0679d52e60351e6db4a88b13997be'><input  type=\"radio\" name=\"input_hsaaadtoepcpeoa\" data-name=\"input_hsaaadtoepcpeoa\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsaaadtoepcpeoa_c6a0679d52e60351e6db4a88b13997be' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsaaadtoepcpeoa_f5fe801e2d54771160f2d7ba9c1e9411'><input  type=\"radio\" name=\"input_hsaaadtoepcpeoa\" data-name=\"input_hsaaadtoepcpeoa\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hsaaadtoepcpeoa_f5fe801e2d54771160f2d7ba9c1e9411' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.31%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_detalle_hsaaadtoepcpeoa' id='label_ff_3_input_detalle_hsaaadtoepcpeoa' aria-label=\"Detalle\">Detalle<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_detalle_hsaaadtoepcpeoa\" class=\"ff-el-form-control\" data-name=\"input_detalle_hsaaadtoepcpeoa\" id=\"ff_3_input_detalle_hsaaadtoepcpeoa\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_29\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.69%;'><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sido evaluado m\u00e9dicamente por exposici\u00f3n a ruido, s\u00edlice, sustancias qu\u00edmicas u otros agentes ocupacionales?\">\u00bfHa sido evaluado m\u00e9dicamente por exposici\u00f3n a ruido, s\u00edlice, sustancias qu\u00edmicas u otros agentes ocupacionales?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsempearssquoao_9b9d3d93c1f6e8b24d0fb9f174edd8ef'><input  type=\"radio\" name=\"input_hsempearssquoao\" data-name=\"input_hsempearssquoao\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsempearssquoao_9b9d3d93c1f6e8b24d0fb9f174edd8ef' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsempearssquoao_6c508fb4e88712c19372aeb63fd0ad58'><input  type=\"radio\" name=\"input_hsempearssquoao\" data-name=\"input_hsempearssquoao\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hsempearssquoao_6c508fb4e88712c19372aeb63fd0ad58' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.31%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_cfeae' id='label_ff_3_input_cfeae' aria-label=\"\u00bfCu\u00e1l fue el agente evaluado?\">\u00bfCu\u00e1l fue el agente evaluado?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_cfeae\" class=\"ff-el-form-control\" data-name=\"input_cfeae\" id=\"ff_3_input_cfeae\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_rdle' id='label_ff_3_input_rdle' aria-label=\"Resultado de la evaluaci\u00f3n\">Resultado de la evaluaci\u00f3n<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_rdle\" class=\"ff-el-form-control\" data-name=\"input_rdle\" id=\"ff_3_input_rdle\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_fopdce' id='label_ff_3_input_fopdce' aria-label=\"Frecuencia o periodicidad de control establecida\">Frecuencia o periodicidad de control establecida<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_fopdce\" class=\"ff-el-form-control\" data-name=\"input_fopdce\" id=\"ff_3_input_fopdce\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_5\" ><h4><i>Declaro que la informaci\u00f3n suministrada es totalmente verdadera, asumiendo toda responsabilidad en caso de omisi\u00f3n<\/i><\/h4><\/div><div class='ff-el-group ff-text-center ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn 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