{"status":"success","response":"<div id=\"custom_forms\">\n\n<div class=\"report_row\" id=\"custom_field_row_1\"><h4>Nome da v\u00edtima<span class='required'> *<\/span> <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[1]\" value=\"\" id=\"custom_field_1\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_34\"><h4>Data<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[34]\" value=\"\"  id=\"custom_field_34\" class=\"text\" \/><script type=\"text\/javascript\">\n\t\t\t\t$(document).ready(function() {\n\t\t\t\t$(\"#custom_field_34\").datepicker({\n\t\t\t\tshowOn: \"both\",\n\t\t\t\tbuttonImage: \"https:\/\/c683652.ssl.cf2.rackcdn.com\/media\/img\/icon-calendar.gif\",\n\t\t\t\tbuttonImageOnly: true\n\t\t\t\t});\n\t\t\t\t});\n\t\t\t<\/script><\/div><div class=\"report_row\" id=\"custom_field_row_3\"><h4>Hor\u00e1rio aproximado <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[3]\" value=\"\" id=\"custom_field_3\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_4\"><h4>Endere\u00e7o<span class='required'> *<\/span> <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[4]\" value=\"\" id=\"custom_field_4\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_5\"><h4>Ve\u00edculo - Modelo <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[5]\" value=\"\" id=\"custom_field_5\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_6\"><h4>Cor do ve\u00edculo <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[6]\" value=\"\" id=\"custom_field_6\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_7\"><h4>Placa do ve\u00edculo ou prefixo de taxi <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[7]\" value=\"\" id=\"custom_field_7\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_8\"><h4>Nome do infrator <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[8]\" value=\"\" id=\"custom_field_8\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_9\"><h4>Prestou socorro? <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[9]\" value=\"\" id=\"custom_field_9\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_35\"><h4>Que tipo agress\u00e3o - verbal, f\u00edsica<span class='required'> *<\/span> <\/h4><textarea name=\"custom_field[35]\" id=\"custom_field_35\" class=\"textarea custom_text\" rows=\"3\"><\/textarea><\/div><div class=\"report_row\" id=\"custom_field_row_36\"><h4>Como aconteceu o acidente? (relate com todos os detalhes poss\u00edveis)<span class='required'> *<\/span> <\/h4><textarea name=\"custom_field[36]\" id=\"custom_field_36\" class=\"textarea custom_text\" rows=\"3\"><\/textarea><\/div><div class=\"report_row\" id=\"custom_field_row_11\"><h4>Houve testemunhas?<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[11]\" value=\"\" id=\"custom_field_11\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_12\"><h4>Ocorr\u00eancia policial (n\u00e3o \/ sim - n\u00famero)<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[12]\" value=\"\" id=\"custom_field_12\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_13\"><h4>Ocorr\u00eancia EPTC (n\u00e3o \/ sim - n\u00famero)<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[13]\" value=\"\" id=\"custom_field_13\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_14\"><h4>Boletim m\u00e9dico (n\u00e3o \/ sim - n\u00famero)<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[14]\" value=\"\" id=\"custom_field_14\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_37\"><h4>Observa\u00e7\u00f5es (outras informa\u00e7\u00f5es) <\/h4><textarea name=\"custom_field[37]\" id=\"custom_field_37\" class=\"textarea custom_text\" rows=\"3\"><\/textarea><\/div><div class=\"report_row\" id=\"custom_field_row_25\"><h4>Este evento resultou em \u00f3bito da v\u00edtima? (sim ou n\u00e3o)<span class='required'> *<\/span> <span class=\"private\">(Private)<\/span><\/h4><input type=\"text\" name=\"custom_field[25]\" value=\"\" id=\"custom_field_25\" class=\"text custom_text\" \/><\/div><\/div>"}