{"status":"success","response":"<div id=\"custom_forms\">\n\n<div class=\"report_row\" id=\"custom_field_row_10\"><h4>Date Reported Event Occured <\/h4><input type=\"text\" name=\"custom_field[10]\" value=\"\"  id=\"custom_field_10\" class=\"text\" \/><script type=\"text\/javascript\">\n\t\t\t\t$(document).ready(function() {\n\t\t\t\t$(\"#custom_field_10\").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_11\"><h4>Property Type <\/h4><span class=\"custom-field-option\"><label for=\"custom_field[11]\" > Residential <\/label><input type=\"radio\" name=\"custom_field[11]\" value=\"Residential\" id=\"custom_field_11\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[11]\" > Business <\/label><input type=\"radio\" name=\"custom_field[11]\" value=\"Business\" id=\"custom_field_11\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[11]\" > Public Area <\/label><input type=\"radio\" name=\"custom_field[11]\" value=\"Public Area\" id=\"custom_field_11\" \/><\/span><\/div><div class=\"custom_div\" id=\"custom_field_3\" ><h2>If you had flooding, how deep was the water?<\/h2><div id=\"custom_field_3_inner\"><div class=\"report_row\" id=\"custom_field_row_2\"><h4>Basement depth (inches) <\/h4><input type=\"text\" name=\"custom_field[2]\" value=\"\" id=\"custom_field_2\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_4\"><h4>Ground floor or Lowest level depth (inches) <\/h4><input type=\"text\" name=\"custom_field[4]\" value=\"\" id=\"custom_field_4\" class=\"text custom_text\" \/><\/div><\/div><\/div><div class=\"report_row\" id=\"custom_field_row_6\"><h4>Did your electricity go out during the flood? <\/h4><span class=\"custom-field-option\"><label for=\"custom_field[6]\" > Yes <\/label><input type=\"radio\" name=\"custom_field[6]\" value=\"Yes\" id=\"custom_field_6\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[6]\" > No <\/label><input type=\"radio\" name=\"custom_field[6]\" value=\"No\" id=\"custom_field_6\" \/><\/span><\/div><div class=\"report_row\" id=\"custom_field_row_7\"><h4>Did you call the EOC Call Center or Public Works Call Center? <\/h4><span class=\"custom-field-option\"><label for=\"custom_field[7]\" > Yes <\/label><input type=\"radio\" name=\"custom_field[7]\" value=\"Yes\" id=\"custom_field_7\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[7]\" > No <\/label><input type=\"radio\" name=\"custom_field[7]\" value=\"No\" id=\"custom_field_7\" \/><\/span><\/div><div class=\"report_row\" id=\"custom_field_row_8\"><h4>Have you registered with FEMA? <\/h4><span class=\"custom-field-option\"><label for=\"custom_field[8]\" > Yes <\/label><input type=\"radio\" name=\"custom_field[8]\" value=\"Yes\" id=\"custom_field_8\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[8]\" > No <\/label><input type=\"radio\" name=\"custom_field[8]\" value=\"No\" id=\"custom_field_8\" \/><\/span><\/div><\/div>"}