3254 lines
295 KiB
PHP
Executable File
3254 lines
295 KiB
PHP
Executable File
<?php
|
||
$documentsarr=array();
|
||
$documentsrem=array();
|
||
$documentsid=array();
|
||
$documentsno=array();
|
||
foreach($documents as $document){
|
||
$documentsarr[$document->documents_type][]=$document->path.$document->file_name;
|
||
$documentsrem[$document->documents_type][]=$document->remarks;
|
||
$documentsid[$document->documents_type][]=$document->id;
|
||
$documentsno[$document->documents_type][]=$document->documents_no;
|
||
//echo '<pre>'; print_r($document); echo '</pre>';
|
||
}
|
||
$traing_doc_count=count($documentsarr[_DOC_TRAININGCODE_]);
|
||
$other_doc_count=count($documentsarr[_DOC_OTHERCODE_]);
|
||
$additional_certificate_count=count($documentsarr[_ADDL_CERTIFICATE_]);
|
||
?>
|
||
<!--sidebar end-->
|
||
<!--main content start-->
|
||
<style type="text/css">
|
||
.required-field:after {
|
||
content: "*";
|
||
color: red;
|
||
}
|
||
.verification-tab{
|
||
background-color: aliceblue;
|
||
}
|
||
</style>
|
||
<?php if($this->session->flashdata('feedback_error')){ ?>
|
||
<script>
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: '<?php echo $this->session->flashdata('feedback_error'); ?>',
|
||
showConfirmButton: false,
|
||
timer: 3500
|
||
})
|
||
</script>
|
||
<?php } ?>
|
||
<?php if($this->session->flashdata('feedback_success')){ ?>
|
||
<script>
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'success',
|
||
title: '<?php echo $this->session->flashdata('feedback_success'); ?>',
|
||
showConfirmButton: false,
|
||
timer: 3500
|
||
})
|
||
</script>
|
||
<?php } ?>
|
||
|
||
<div class="app-content content">
|
||
<section class="content-wrapper">
|
||
<div class="row">
|
||
<div class="col-12">
|
||
<div class="card">
|
||
<div class="card-header">
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<h3 class="font-weight-bold">
|
||
<?php
|
||
echo lang('Caregiver Acceptence');
|
||
?>
|
||
</h3>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr class="mt-0 mb-0" />
|
||
|
||
<div class="card-content collapse show">
|
||
<div class="card-body card-dashboard">
|
||
<div class="col-lg-12">
|
||
<ul class="nav nav-tabs nav-linetriangle no-hover-bg" id="myTab" role="tablist" style="border-bottom-color: #1e9ef1;; margin-bottom: 20px; border-radius: 0px;">
|
||
<li class="nav-item">
|
||
<a class="nav-link <?php if (!$nurse->verification) echo 'active'; ?> " id="INTERNAL-tab" data-toggle="tab" href="#INTERNAL" role="tab" aria-controls="INTERNAL" aria-selected="true">Verifications</a>
|
||
</li>
|
||
<li class="nav-item ">
|
||
<a class="nav-link <?php if (!$nurse->verification) echo 'disabled'; ?> <?php if ($tab==2) echo 'active'; ?>" data-toggle="tab" href="#tab8" role="tab" aria-selected="false"> <?php if($progress->form8 < 10){ ?><?php } ?>Physical Examination Form</a>
|
||
</li>
|
||
<li class="nav-item ">
|
||
<a class="nav-link <?php if (!$nurse->verification) echo 'disabled'; ?> <?php if ($tab==3) echo 'active'; ?>" data-toggle="tab" href="#tab9" role="tab" aria-selected="false"> <?php if($progress->form9 < 10){ ?> <?php } ?>Required Employee Health Assesment</a>
|
||
</li>
|
||
<li class="nav-item ">
|
||
<a class="nav-link <?php if (!$nurse->verification) echo 'disabled'; ?> <?php if ($tab==4) echo 'active'; ?>" data-toggle="tab" href="#tab10" role="tab" aria-selected="false"><?php if($progress->form10 < 10){ ?> <?php } ?>Hapatitis B Vaccine Acceptence</a>
|
||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link <?php if (!$nurse->verification) echo 'disabled'; ?> <?php if ($tab==5) echo 'active'; ?>" id="ACCEPTENCE-tab" data-toggle="tab" href="#ACCEPTENCE" role="tab" aria-controls="ACCEPTENCE" aria-selected="false">Pending Acceptence</a>
|
||
</li>
|
||
</ul>
|
||
<div class="tab-content">
|
||
<div class="tab-pane fade <?php if (!$nurse->verification) echo 'show active'; ?>" id="INTERNAL" role="tabpanel" aria-labelledby="INTERNAL-tab" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>caregivers/internalProcess" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation" >
|
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<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<!--data-toggle="validator" novalidate="true"-->
|
||
<input type="hidden" name="caregiver_id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<input type="hidden" name="status" value="1">
|
||
<div class="row">
|
||
<div class="row col-md-12">
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Back Ground'); ?></label>
|
||
<input type="file" class="form-control" name="chrc" id="exampleInputEmail1" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('chrc');
|
||
}
|
||
if (!empty($nurse->verification->chrc)) {
|
||
echo $nurse->verification->chrc;
|
||
}
|
||
?>' data-error="Please enter a file name.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<div class="row">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Finger Print'); ?></label>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="finger_print_yes" name="finger_print" value="1" <?php if ($nurse->verification->finger_print=='1') {
|
||
echo "checked"; } ?> >
|
||
<label class="form-check-label" for="finger_print_yes" >Yes</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="finger_print_no" name="finger_print" value="0" <?php if ($nurse->verification->live_with_patient=='0') {
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||
echo "checked"; } ?> >
|
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<label class="form-check-label" for="live_with_patient_no">No</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row col-md-12">
|
||
<div class="form-group col-md-4">
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||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('Submission Date'); ?></label>
|
||
<input type="date" class="form-control ftrDate" name="submission_date" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('submission_date');
|
||
}
|
||
if (!empty($nurse->verification->submission_date)) {
|
||
echo $nurse->verification->submission_date;
|
||
}
|
||
?>' required data-error="Please enter a submission date.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('Submission Results'); ?></label>
|
||
<select class="form-control" name="submission_result">
|
||
|
||
<option value="submitted" <?php
|
||
if (!empty($nurse->verification->submission_result)) {
|
||
if ($nurse->verification->submission_result == 'submitted') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Submitted</option>
|
||
<option value="resubmitted" <?php
|
||
|
||
if (!empty($nurse->verification->submission_result)) {
|
||
if ($nurse->verification->submission_result == 'resubmitted') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Resubmitted</option>
|
||
<option value="non-indent" <?php
|
||
|
||
if (!empty($nurse->verification->submission_result)) {
|
||
if ($nurse->verification->submission_result == 'non-indent') {
|
||
echo 'selected';
|
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}
|
||
}
|
||
?> >Non-indent</option>
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<option value="temporary_denial" <?php
|
||
|
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if (!empty($nurse->verification->submission_result)) {
|
||
if ($nurse->verification->submission_result == 'temporary_denial') {
|
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echo 'selected';
|
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}
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}
|
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?> >Temporary Denial</option>
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<option value="final_denial" <?php
|
||
|
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if (!empty($nurse->verification->submission_result)) {
|
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if ($nurse->verification->submission_result == 'final_denial') {
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echo 'selected';
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}
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}
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?> >Final Denial</option>
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<option value="ChargeNotificationAfterHire" <?php
|
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if (!empty($nurse->verification->submission_result)) {
|
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if ($nurse->verification->submission_result == 'ChargeNotificationAfterHire') {
|
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echo 'selected';
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}
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}
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?> >Charge Notification After Hire</option>
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<option value="NoConvictionNoHitLetter" <?php
|
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if (!empty($nurse->verification->submission_result)) {
|
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if ($nurse->verification->submission_result == 'NoConvictionNoHitLetter') {
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echo 'selected';
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}
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}
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?> >No Conviction/No Hit Letter</option>
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</select>
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<div class="help-block with-errors"></div>
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</div>
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<!-- <div class="form-group col-md-4">
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<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('Submission Results Other'); ?></label>
|
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<input type="text" class="form-control" name="submission_result_other" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('submission_result_other');
|
||
}
|
||
if (!empty($nurse->verification->submission_result_other)) {
|
||
echo $nurse->verification->submission_result_other;
|
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}
|
||
?>' placeholder="" required data-error="Please enter submission result other.">
|
||
<div class="help-block with-errors"></div>
|
||
</div> -->
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('Results Received Date'); ?></label>
|
||
<input type="date" class="form-control ftrDate" name="results_receive_date" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('results_receive_date');
|
||
}
|
||
if (!empty($nurse->verification->results_receive_date)) {
|
||
echo $nurse->verification->results_receive_date;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter Results Received Date.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('State or Federal ID'); ?></label>
|
||
<input type="text" class="form-control" name="nysid" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('nysid');
|
||
}
|
||
if (!empty($nurse->verification->nysid)) {
|
||
echo $nurse->verification->nysid;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter nysid.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row col-md-12" style="padding: 20px">
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Second Submission Date'); ?></label>
|
||
<input type="date" class="form-control ftrDate" name="second_submission_date" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('second_submission_date');
|
||
}
|
||
if (!empty($nurse->verification->second_submission_date)) {
|
||
echo $nurse->verification->second_submission_date;
|
||
}
|
||
?>' >
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Submission Results'); ?></label>
|
||
<select class="form-control" name="second_submission_result">
|
||
|
||
<option value="submitted" <?php
|
||
if (!empty($setval)) {
|
||
if ('submitted' == set_value('second_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->second_submission_result)) {
|
||
if ($nurse->verification->second_submission_result == 'submitted') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Submitted</option>
|
||
<option value="resubmitted" <?php
|
||
if (!empty($setval)) {
|
||
if ('resubmitted' == set_value('second_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->second_submission_result)) {
|
||
if ($nurse->verification->second_submission_result == 'resubmitted') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Resubmitted</option>
|
||
<option value="ok" <?php
|
||
if (!empty($setval)) {
|
||
if ('ok' == set_value('second_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->second_submission_result)) {
|
||
if ($nurse->verification->second_submission_result == 'ok') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >OK</option>
|
||
<option value="temporary_denial" <?php
|
||
if (!empty($setval)) {
|
||
if ('temporary_denial' == set_value('second_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->second_submission_result)) {
|
||
if ($nurse->verification->second_submission_result == 'temporary_denial') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Temporary Denial</option>
|
||
<option value="final_denial" <?php
|
||
if (!empty($setval)) {
|
||
if ('final_denial' == set_value('second_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->second_submission_result)) {
|
||
if ($nurse->verification->second_submission_result == 'final_denial') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Final Denial</option>
|
||
</select>
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<!-- <div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Submission Results Other'); ?></label>
|
||
<input type="text" class="form-control" name="second_submission_result_other" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('second_submission_result_other');
|
||
}
|
||
if (!empty($nurse->verification->second_submission_result_other)) {
|
||
echo $nurse->verification->second_submission_result_other;
|
||
}
|
||
?>' placeholder="">
|
||
<div class="help-block with-errors"></div>
|
||
</div> -->
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Results Received Date'); ?></label>
|
||
<input type="date" class="form-control ftrDate" name="second_results_receive_date" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('second_results_receive_date');
|
||
}
|
||
if (!empty($nurse->verification->second_results_receive_date)) {
|
||
echo $nurse->verification->second_results_receive_date;
|
||
}
|
||
?>' placeholder="" >
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('NYSID'); ?></label>
|
||
<input type="text" class="form-control" name="second_nysid" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('second_nysid');
|
||
}
|
||
if (!empty($nurse->verification->second_nysid)) {
|
||
echo $nurse->verification->second_nysid;
|
||
}
|
||
?>' placeholder="" >
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
</div>
|
||
<div class="row col-md-12" style="padding: 20px">
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Submission Date'); ?></label>
|
||
<input type="date" class="form-control ftrDate" name="third_submission_date" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('third_submission_date');
|
||
}
|
||
if (!empty($nurse->verification->third_submission_date)) {
|
||
echo $nurse->verification->third_submission_date;
|
||
}
|
||
?>' >
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Submission Results'); ?></label>
|
||
<select class="form-control" name="third_submission_result">
|
||
<option value="submitted" <?php
|
||
if (!empty($setval)) {
|
||
if ('submitted' == set_value('third_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->preferred_contact)) {
|
||
if ($nurse->verification->preferred_contact == 'submitted') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Submitted</option>
|
||
<option value="resubmitted" <?php
|
||
if (!empty($setval)) {
|
||
if ('resubmitted' == set_value('third_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->preferred_contact)) {
|
||
if ($nurse->verification->preferred_contact == 'resubmitted') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >ReSubmitted</option>
|
||
<option value="ok" <?php
|
||
if (!empty($setval)) {
|
||
if ('ok' == set_value('third_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->preferred_contact)) {
|
||
if ($nurse->verification->preferred_contact == 'ok') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >OK</option>
|
||
<option value="temporary_denial" <?php
|
||
if (!empty($setval)) {
|
||
if ('temporary_dental' == set_value('third_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->preferred_contact)) {
|
||
if ($nurse->verification->preferred_contact == 'temporary_denial') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Temporary Denial</option>
|
||
<option value="final_dental" <?php
|
||
if (!empty($setval)) {
|
||
if ('final_denial' == set_value('third_submission_result')) {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
if (!empty($nurse->verification->preferred_contact)) {
|
||
if ($nurse->verification->preferred_contact == 'final_denial') {
|
||
echo 'selected';
|
||
}
|
||
}
|
||
?> >Final Denial</option>
|
||
</select>
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<!-- <div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Submission Results Other'); ?></label>
|
||
<input type="text" class="form-control" name="third_submission_result_other" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('third_submission_result_other');
|
||
}
|
||
if (!empty($nurse->verification->third_submission_result_other)) {
|
||
echo $nurse->verification->third_submission_result_other;
|
||
}
|
||
?>' placeholder="" >
|
||
<div class="help-block with-errors"></div>
|
||
</div> -->
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('Results Received Date'); ?></label>
|
||
<input type="date" class="form-control ftrDate" name="third_results_receive_date" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('third_results_receive_date');
|
||
}
|
||
if (!empty($nurse->verification->third_results_receive_date)) {
|
||
echo $nurse->verification->third_results_receive_date;
|
||
}
|
||
?>' placeholder="" >
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('NYSID'); ?></label>
|
||
<input type="text" class="form-control" name="third_nysid" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('third_nysid');
|
||
}
|
||
if (!empty($nurse->verification->third_nysid)) {
|
||
echo $nurse->verification->third_nysid;
|
||
}
|
||
?>' placeholder="" >
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
</div>
|
||
<div class="row col-md-12" style="padding: 20px">
|
||
<?php if($nurse->state1 =='NY'){
|
||
if($nurse->qualification_type == 4 || $nurse->qualification_type == 5){
|
||
?>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('NY State Licenses Number'); ?></label>
|
||
<input type="text" class="form-control" name="state_lic_no" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('state_lic_no');
|
||
}
|
||
if (!empty($nurse->verification->state_lic_no)) {
|
||
echo $nurse->verification->state_lic_no;
|
||
}
|
||
?>' required data-error="Please enter State Licenses Number.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<?php } ?>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('NY State Licenses Expiration'); ?></label>
|
||
<input type="date" class="form-control" name="state_lic_exp" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('state_lic_exp');
|
||
}
|
||
if (!empty($nurse->verification->state_lic_exp)) {
|
||
echo $nurse->verification->state_lic_exp;
|
||
}
|
||
?>' required data-error="Please enter State Licenses Number.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<?php if($nurse->qualification_type == '6' || $nurse->qualification_type == '7'){ ?>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('NY State Registry Check'); ?></label>
|
||
<input type="text" class="form-control" name="state_reg_check" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('state_reg_check');
|
||
}
|
||
if (!empty($nurse->verification->state_reg_check)) {
|
||
echo $nurse->verification->state_reg_check;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter NY State Registry Check.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<?php } ?>
|
||
<?php if($nurse->qualification_type == '4' || $nurse->qualification_type -= '5'){ ?>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('NY State Verification'); ?></label>
|
||
<input type="text" class="form-control" name="state_verification" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('state_verification');
|
||
}
|
||
if (!empty($nurse->verification->state_verification)) {
|
||
echo $nurse->verification->state_verification;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter NY State Verification.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<?php } } ?>
|
||
<?php if($nurse->qualification_type == '4' || $nurse->qualification_type -= '5'){ ?>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold">
|
||
<?php echo lang('NPI Number'); ?>
|
||
</label>
|
||
<div class="input-group">
|
||
<input type="text" class="form-control" name="npi_no" id ="checkNpi_no" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('npi_no');
|
||
}
|
||
if (!empty($nurse->verification->npi_no)) {
|
||
echo $nurse->verification->npi_no;
|
||
}
|
||
?>' minlength="10" maxlength="10" placeholder="" onkeypress="return isNumberKey(event)" required data-error="Please enter npi.">
|
||
<div class="input-group-append" id="npivalidateTab" style="display: none;">
|
||
<span class="input-group-text" >
|
||
<span id="npiNoValidating" style="display: none"><i class="la la-hourglass-start" style="color: blue;"></i></span>
|
||
<span id="npiValid" style="display: none"><i class="la la-check" style="color: green;">Valid</i></span>
|
||
<span id="npiinValid" style="display: none"><i class="la la-close" style="color: red;">Invalid</i></span>
|
||
</span>
|
||
</div>
|
||
</div>
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
|
||
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold">
|
||
<?php echo lang('Malpractice Ins Policy'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="malpractice_insurence" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('malpractice_insurence');
|
||
}
|
||
if (!empty($nurse->verification->malpractice_insurence)) {
|
||
echo $nurse->verification->malpractice_insurence;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter Malpractice Insurance Policy.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<?php } ?>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold">
|
||
<!-- <?php echo lang('Carrier Name'); ?> -->
|
||
<?php echo lang('Auto Policy Carrier Name'); ?>
|
||
</label>
|
||
<input type="text" class="form-control" name="carrier" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('carrier');
|
||
}
|
||
if (!empty($nurse->verification->carrier)) {
|
||
echo $nurse->verification->carrier;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter Carrier name.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('Auto Policy'); ?></label>
|
||
<input type="text" class="form-control" name="policy_no" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('policy_no');
|
||
}
|
||
if (!empty($nurse->verification->policy_no)) {
|
||
echo $nurse->verification->policy_no;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter Auto Policy.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold">
|
||
<?php echo lang('Auto Policy Expiration Date'); ?>
|
||
</label>
|
||
<input type="date" class="form-control ftrDate" name="exp_date" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('exp_date');
|
||
}
|
||
if (!empty($nurse->verification->exp_date)) {
|
||
echo $nurse->verification->exp_date;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter Expiration Date.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold">
|
||
<?php echo lang('Automobile Insurance Policy'); ?>
|
||
</label>
|
||
<input type="date" class="form-control" name="automobile_insurence_policy" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('automobile_insurence_policy ');
|
||
}
|
||
if (!empty($nurse->verification->automobile_insurence_policy)) {
|
||
echo $nurse->verification->automobile_insurence_policy;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter Automobile Insurance Policy.">
|
||
<div class="help-block with-errors"></div>
|
||
<?php if($nurse->qualification_type == '4' || $nurse->qualification_type -= '5'){ ?>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('CPR Certification (Expiration Date)'); ?></label>
|
||
<input type="date" class="form-control" name="cpr_certification" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('cpr_certification ');
|
||
}
|
||
if (!empty($nurse->verification->cpr_certification)) {
|
||
echo $nurse->verification->cpr_certification;
|
||
}
|
||
?>' placeholder="" required data-error="Please enter CPR Certification (Expiration Date).">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('Additional Certifications'); ?></label>
|
||
<input type="date" class="form-control ftrDate" name="aditional_certification" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('aditional_certification ');
|
||
}
|
||
if (!empty($nurse->verification->aditional_certification)) {
|
||
echo $nurse->verification->aditional_certification;
|
||
}
|
||
?>' placeholder="" required data-error="Additional Certifications.">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<?php } ?>
|
||
</div>
|
||
<div class="row col-md-12" style="padding: 20px">
|
||
<div class="form-group col-md-6">
|
||
<div class="row">
|
||
<label for="exampleInputEmail1" class="font-weight-bold"><?php echo lang('OMIG'); ?></label>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-check col-md-4 mx-1">
|
||
<input class="form-check-input" type="radio" id="omig_yes" name="omig" value="1" <?php if ($nurse->verification->omig=='1') {
|
||
echo "checked"; } ?> >
|
||
<label class="form-check-label" for="omig_yes" >Employable</label>
|
||
</div>
|
||
<div class="form-check col-md-4 mx-1">
|
||
<input class="form-check-input" type="radio" id="omig_no" name="omig" value="0" <?php if ($nurse->verification->omig=='0') {
|
||
echo "checked"; } ?> >
|
||
<label class="form-check-label" for="omig_no">Cannot Employ</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field font-weight-bold"><?php echo lang('Notes'); ?></label>
|
||
<input type="text" class="form-control" name="notes" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('notes');
|
||
}
|
||
if (!empty($nurse->verification->notes)) {
|
||
echo $nurse->verification->notes;
|
||
}
|
||
?>' placeholder="" required data-error="notes">
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
</div>
|
||
<div class="col-md-12">
|
||
<button type="submit" id="approve_submitBtn" name="submit" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
</div>
|
||
<script>
|
||
$("#checkNpi_no").blur(function(){
|
||
var npi_no=$("input[name=npi_no]").val();
|
||
if(npi_no!=""){
|
||
$.ajax({
|
||
url:'<?=base_url()?>referral/getNpiData?code='+npi_no,
|
||
type :'GET',
|
||
dataType: "json",
|
||
beforeSend: function() {
|
||
$("#npiValid").hide();
|
||
$("#npiinValid").hide();
|
||
$("#npiNoValidating").show();
|
||
$("#npivalidateTab").show();
|
||
$(".check-npi").hide();
|
||
$("#approve_submitBtn").prop('disabled', true);
|
||
},
|
||
success:function(data){
|
||
console.log(data);
|
||
$('#phymdfName').val(data.fname);
|
||
if(data.license)
|
||
{
|
||
$("#npivalidate").val('valid');
|
||
$("#npiValid").show();
|
||
$("#npiinValid").hide();
|
||
$("#npiNoValidating").hide();
|
||
$("#approve_submitBtn").prop('disabled', false);
|
||
}
|
||
else
|
||
{
|
||
$("#npivalidate").val('invalid');
|
||
$("#npiValid").hide();
|
||
$("#npiinValid").show();
|
||
$("#npiNoValidating").hide();
|
||
$(".check-npi").show();
|
||
$("#approve_submitBtn").prop('disabled', true);
|
||
}
|
||
}
|
||
});
|
||
}else{
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Please enter npi no.',
|
||
showConfirmButton: false,
|
||
timer: 1500
|
||
});
|
||
}
|
||
});
|
||
|
||
function isNumberKey(evt) {
|
||
var charCode = (evt.which) ? evt.which : evt.keyCode;
|
||
if (charCode > 31 && (charCode < 48 || charCode > 57))
|
||
return false;
|
||
return true;
|
||
}
|
||
</script>
|
||
</form>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<div class="tab-pane fade <?php if($tab==2) {?> active in show <?php } ?>" id="tab8" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>caregivers/saveCaregiverPhysicalExamForm" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<!--data-toggle="validator" novalidate="true"-->
|
||
<!-- <input type="hidden" name="form_tab_status" value="8"> -->
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<!-- <input type="hidden" name="form_status" value="8"> -->
|
||
<!-- <input type="hidden" name="form_mode" value="<?php if($nurse->form_status>0) echo 'Edit'; else echo 'Add'; ?>"> -->
|
||
<div class="row">
|
||
<?php $physical_exam_form=json_decode($nurse->physical_exam_form) ?>
|
||
<div class="form-group col-md-5">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Name'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->fname)) {
|
||
echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
<div class="form-group col-md-5">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('DOB'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->dob)) {
|
||
echo $nurse->dob;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
<div class="form-group col-md-2 mt-2 mt-25">
|
||
<!-- <a class="btn btn-primary file-upload" href="<?php echo base_url(); ?>uploads/phy.pdf" target="_blank" download> Download</a> -->
|
||
</div>
|
||
</div>
|
||
<?php
|
||
if(!empty($physical_exam_form->height_feet))
|
||
$height=explode('/', $physical_exam_form->height_feet);
|
||
else
|
||
$height='';
|
||
// if(!empty($physical_exam_form->height_inches))
|
||
// $height_inches=explode('/', $physical_exam_form->height_inches);
|
||
// else
|
||
// $height_inches='';
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-2">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Height (feet)'); ?></label>
|
||
<select class="form-control" name="height_feet" required data-error="Please enter a valid height.">
|
||
<option value="" selected disabled>Select</option>
|
||
<?php for($i=1;$i<10;$i++){ ?>
|
||
<option value="<?php echo $i; ?>" <?php if($height[0]==$i) echo 'selected'; ?>><?php echo $i; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-2">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('(inches)'); ?></label>
|
||
|
||
<select class="form-control" name="height_inches" required data-error="Please enter a valid height.">
|
||
<option value="" selected disabled>Select</option>
|
||
<?php for($i=0;$i<12;$i++){ ?>
|
||
<option value="<?php echo $i; ?>" <?php if($physical_exam_form->height_inches==$i) echo 'selected'; ?>><?php echo $i; ?></option>
|
||
<?php } ?>
|
||
</select>
|
||
<div class="help-block with-errors"></div>
|
||
</div>
|
||
<div class="form-group col-md-2">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Blood Pressure'); ?></label>
|
||
<input type="text" name="blood_pressure" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->blood_pressure)) {
|
||
echo $physical_exam_form->blood_pressure;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-2">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Pulse'); ?></label>
|
||
<input type="text" name="pulse" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->pulse)) {
|
||
echo $physical_exam_form->pulse;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-2">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Respiration'); ?></label>
|
||
<input type="text" name="respiration" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->respiration)) {
|
||
echo $physical_exam_form->respiration;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-2">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Weight'); ?></label>
|
||
<input type="text" name="weight" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->weight)) {
|
||
echo $physical_exam_form->weight;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Heart'); ?></label>
|
||
<input type="text" name="heart" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->heart)) {
|
||
echo $physical_exam_form->heart;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Lungs'); ?></label>
|
||
<input type="text" name="lungs" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->lungs)) {
|
||
echo $physical_exam_form->lungs." ".$nurse->lungs;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Muscular-Skeleta'); ?></label>
|
||
<input type="text" name="muscular_skeleta" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->muscular_skeleta)) {
|
||
echo $physical_exam_form->muscular_skeleta;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('GU'); ?></label>
|
||
<input type="text" name="gu" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->gu)) {
|
||
echo $physical_exam_form->gu;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('GI'); ?></label>
|
||
<input type="text" name="gi" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->gi)) {
|
||
echo $physical_exam_form->gi;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-6">
|
||
<label><?php echo lang('Tests Required by Law of ALL Males & Females'); ?></label>
|
||
|
||
<!-- <tr>
|
||
<td></td>
|
||
<td>Test Date</td>
|
||
<td>Result in mm</td>
|
||
<td>Result Date</td>
|
||
</tr> -->
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
</div>
|
||
<div class="col-md-3">
|
||
<label>Test Date</label>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<label>Result in mm</label>
|
||
</div>
|
||
<div class="col-md-3">
|
||
<label>Result Date</label>
|
||
</div>
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
<label>PPD (Mantoux)</label></div>
|
||
<div class="col-md-3"><input type="date" name="ppd1_testDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->ppd1_testDate)) {
|
||
echo $physical_exam_form->ppd1_testDate;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="text" name="ppd1_result" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->ppd1_result)) {
|
||
echo $physical_exam_form->ppd1_result;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="date" name="ppd1_resultDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->ppd1_resultDate)) {
|
||
echo $physical_exam_form->ppd1_resultDate;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
|
||
|
||
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
<label>PPD (Mantoux) 2nd</label></div>
|
||
<div class="col-md-3"><input type="date" name="ppd2_testDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->ppd2_testDate)) {
|
||
echo $physical_exam_form->ppd2_testDate;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="text" name="ppd2_result" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->ppd2_result)) {
|
||
echo $physical_exam_form->ppd2_result;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="date" name="ppd2_resultDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->ppd2_resultDate)) {
|
||
echo $physical_exam_form->ppd2_resultDate;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
<label>X-Ray if positive PPD</label></div>
|
||
<div class="col-md-3"><input type="date" name="xray_testDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->xray_testDate)) {
|
||
echo $physical_exam_form->xray_testDate;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="text" name="xray_result" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->xray_result)) {
|
||
echo $physical_exam_form->xray_result;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="date" name="xray_resultDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->xray_resultDate)) {
|
||
echo $physical_exam_form->xray_resultDate;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
|
||
<label>Rubella Titre</label></div>
|
||
<div class="col-md-3"><input type="date" name="rubella_testDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->rubella_testDate)) {
|
||
echo $physical_exam_form->rubella_testDate;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="text" name="rubella_result" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->rubella_result)) {
|
||
echo $physical_exam_form->rubella_result;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="date" name="rubella_resultDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->rubella_resultDate)) {
|
||
echo $physical_exam_form->rubella_resultDate;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
|
||
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
<label>Rubeola Titre (If born after 11/1/57 Rubeola verified)</label>
|
||
</div>
|
||
<div class="col-md-3"><input type="date" name="rubeola_testDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->rubeola_testDate)) {
|
||
echo $physical_exam_form->rubeola_testDate;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="text" name="rubeola_result" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->rubeola_result)) {
|
||
echo $physical_exam_form->rubeola_result;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"><input type="date" name="rubeola_resultDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->rubeola_resultDate)) {
|
||
echo $physical_exam_form->rubeola_resultDate;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-12"><input type="text" name="rubeola_details" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->rubeola_details)) {
|
||
echo $physical_exam_form->rubeola_details;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
<label>Influenza Vaccine Site:</label></div>
|
||
|
||
<div class="col-md-3"><input type="date" name="influenza_testDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->influenza_testDate)) {
|
||
echo $physical_exam_form->influenza_testDate;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3"></div>
|
||
<div class="col-md-3"><input type="date" name="influenza_resultDate" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->influenza_resultDate)) {
|
||
echo $physical_exam_form->influenza_resultDate;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
|
||
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
<label>-Lot Number:</label></div>
|
||
<div class="col-md-3"><input type="text" name="lot_num" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->lot_num)) {
|
||
echo $physical_exam_form->lot_num;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3">Expiration</div>
|
||
<div class="col-md-3"><input type="date" name="lot_exp" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->lot_exp)) {
|
||
echo $physical_exam_form->lot_exp;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
|
||
</div>
|
||
|
||
|
||
<!-- </div> -->
|
||
|
||
<!-- </tr> -->
|
||
<!-- </div> -->
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
<!-- </div> -->
|
||
<div class="col-md-6">
|
||
<label><?php echo lang('Specify Disease Immunization or Test (May be requested by state or client)'); ?></label>
|
||
<!-- <table> -->
|
||
<!-- <tr>
|
||
<td></td>
|
||
<td colspan="3">Dates(s)</td>
|
||
</tr> -->
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
</div>
|
||
<div class="col-md-9">
|
||
<label>Dates(s)</label>
|
||
</div>
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-3">
|
||
<label>Diphtheria</label></div>
|
||
<div class="col-md-9">
|
||
<input type="date" name="Diphtheria" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->Diphtheria)) {
|
||
echo $physical_exam_form->Diphtheria;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-3"><label>Tetanus</label></div>
|
||
<div class="col-md-9"><input type="date" name="Tetanus" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->Tetanus)) {
|
||
echo $physical_exam_form->Tetanus;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-3"><label>Mumps</label></div>
|
||
<div class="col-md-9"><input type="date" name="Mumps" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->Mumps)) {
|
||
echo $physical_exam_form->Mumps;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-3"> <label>Rubella Vaccine</label></div>
|
||
<div class="col-md-9"><input type="date" name="RubellaVaccine" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->RubellaVaccine)) {
|
||
echo $physical_exam_form->RubellaVaccine;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-3"><label>Measles Vaccine</label></div>
|
||
<div class="col-md-4">1:<input type="date" name="MeaslesVaccine1" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->MeaslesVaccine1)) {
|
||
echo $physical_exam_form->MeaslesVaccine1;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-4">2:<input type="date" name="MeaslesVaccine2" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->MeaslesVaccine2)) {
|
||
echo $physical_exam_form->MeaslesVaccine2;
|
||
}
|
||
?>'></div>
|
||
<!-- <td></td> -->
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-3"> <label>HB Vaccine</label></div>
|
||
<div class="col-md-3">1:<input type="date" name="HB1" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->HB1)) {
|
||
echo $physical_exam_form->HB1;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3">2:<input type="date" name="HB2" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->HB2)) {
|
||
echo $physical_exam_form->HB2;
|
||
}
|
||
?>'></div>
|
||
<div class="col-md-3">3:<input type="date" name="HB3" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->HB3)) {
|
||
echo $physical_exam_form->HB3;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
<div class="row form-group">
|
||
<div class="col-md-3"><label>Drug Screen:</label></div>
|
||
<div class="col-md-9"><input type="date" name="DrugScreen" class="form-control" value='<?php
|
||
if (!empty($physical_exam_form->DrugScreen)) {
|
||
echo $physical_exam_form->DrugScreen;
|
||
}
|
||
?>'></div>
|
||
</div>
|
||
<!-- </table> -->
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Specify any follow-up treatment needed for positive test results or delay due to pregnancy:'); ?></label>
|
||
<input type="text" class="form-control" name="due_to_pregnancy" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->due_to_pregnancy)) {
|
||
echo $physical_exam_form->due_to_pregnancy;
|
||
}
|
||
?>'>
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Medications (List all medications prescribed on a continuing basis):'); ?></label>
|
||
<input type="text" class="form-control" name="list_of_medications" id="exampleInputEmail1" value='<?php
|
||
if (!empty($physical_exam_form->list_of_medications)) {
|
||
echo $physical_exam_form->list_of_medications;
|
||
}
|
||
?>'>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Does this person require eyeglasses?'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="eyeglassesYES" name="eyeglasses" value="1" <?php if ($physical_exam_form->eyeglasses==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="eyeglassesYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="eyeglassesNO" name="eyeglasses" value="0" <?php if ($physical_exam_form->eyeglasses==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="eyeglassesNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-12">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Hearing aide?'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="hearingAidYES" name="hearingAid" value="1" <?php if ($physical_exam_form->hearingAid==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="hearingAidYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="hearingAidNO" name="hearingAid" value="0" <?php if ($physical_exam_form->hearingAid==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="hearingAidNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang(' Has this person been treated for any disease entity or injury which hampered his/her ability to function periods? '); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="injuredyes" name="extended_periods" value="1" <?php if ($physical_exam_form->extended_periods==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="injuredyes">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="injuredno" name="extended_periods" value="0" <?php if ($physical_exam_form->extended_periods==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="injuredno">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="extended_periods_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('extended_periods_explain');
|
||
}
|
||
if (!empty($physical_exam_form->extended_periods_explain)) {
|
||
echo $physical_exam_form->extended_periods_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Is this person presently being treated for any disorders of a chronic or recurring nature? (Please include any history of back injury, congenital defect, brain or nervous disorders, etc.):'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="disordersYES" name="disorders" value="1" <?php if ($physical_exam_form->disorders==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="disordersYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="disordersNO" name="disorders" value="0" <?php if ($physical_exam_form->disorders==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="disordersNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="extended_periods_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('extended_periods_explain');
|
||
}
|
||
if (!empty($physical_exam_form->extended_periods_explain)) {
|
||
echo $physical_exam_form->extended_periods_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
<div class="form-group col-md-12">
|
||
<button type="submit" name="submit" class="btn btn-info" onclick="return validateForm();"><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<div class="tab-pane fade <?php if($tab==3) {?> active in show <?php } ?>" id="tab9" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>caregivers/saveCaregiveremployeeHealthAssessment" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<?php $emp_health_assesment=json_decode($nurse->emp_health_assesment) ?>
|
||
<input type="hidden" name="form_tab_status" value="9">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<input type="hidden" name="form_status" value="9">
|
||
<input type="hidden" name="form_mode" value="<?php if($nurse->form_status>0) echo 'Edit'; else echo 'Add'; ?>">
|
||
<div class="row pull-right">
|
||
<div class="form-group col-md-2 mt-2 mt-25">
|
||
<!-- <a class="btn btn-primary file-upload" href="<?php echo base_url(); ?>uploads/health_Assesment.pdf" target="_blank" download> Download</a> -->
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Name'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->fname)) {
|
||
echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('DOB'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->dob)) {
|
||
echo $nurse->dob;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Sex'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->gender)) {
|
||
echo $nurse->gender;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Address'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->address1)) {
|
||
echo $nurse->address1.",".$nurse->country1.",",$nurse->state1.",".$nurse->city1.",".$nurse->zipcode1;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Emergency Contact'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->Emergency_Contact_Name)) {
|
||
echo $nurse->Emergency_Contact_Name;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
<?php
|
||
$rel = '';
|
||
|
||
foreach($relation as $val){
|
||
if (!empty($nurse->Emergency_Contact_Relationship)) {
|
||
if ($nurse->Emergency_Contact_Relationship == $val->id) {
|
||
$rel= $val->name;
|
||
|
||
} } }?>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Relationship'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->Emergency_Contact_Relationship)) {
|
||
echo $rel;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Emergency Address/Phone number'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->Emergency_Contact_Address)) {
|
||
$x = json_decode($nurse->Emergency_Contact_Address);
|
||
echo $x->Emergency_Contact_Address.','. $x->Emergency_Contact_zipcode;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-6">
|
||
<label>Indicate if you are suffering from or have a history of the following conditions:</label>
|
||
<table class="col-md-6">
|
||
<tr>
|
||
<th>Condition</th>
|
||
<th>Yes</th>
|
||
<th>No</th>
|
||
</tr>
|
||
<tr>
|
||
<td>DIABETES</td>
|
||
<td>
|
||
<input type="radio" name="diabetes" id="radio1" value="1" <?php if ($emp_health_assesment->diabetes==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="diabetes" id="radio1" value="0" <?php if ($emp_health_assesment->diabetes==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>KIDNEY DISEASE</td>
|
||
<td>
|
||
<input type="radio" name="kidney_disease" id="radio1" value="1" <?php if ($emp_health_assesment->kidney_disease==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="kidney_disease" id="radio1" value="0" <?php if ($emp_health_assesment->kidney_disease==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>HEART DISEASE</td>
|
||
<td>
|
||
<input type="radio" name="heart_disease" id="radio1" value="1" <?php if ($emp_health_assesment->heart_disease==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="heart_disease" id="radio1" value="0" <?php if ($emp_health_assesment->heart_disease==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>HIGH BLOOD PRESSURE</td>
|
||
<td>
|
||
<input type="radio" name="high_blood_pressure" id="radio1" value="1" <?php if ($emp_health_assesment->high_blood_pressure==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="high_blood_pressure" id="radio1" value="0" <?php if ($emp_health_assesment->high_blood_pressure==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>ARTHRITIS</td>
|
||
<td>
|
||
<input type="radio" name="arthritis" id="radio1" value="1" <?php if ($emp_health_assesment->arthritis==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="arthritis" id="radio1" value="0" <?php if ($emp_health_assesment->arthritis==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>MENTAL ILLNESS</td>
|
||
<td>
|
||
<input type="radio" name="mental_illness" id="radio1" value="1" <?php if ($emp_health_assesment->mental_illness==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="mental_illness" id="radio1" value="0" <?php if ($emp_health_assesment->mental_illness==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>EPILEPSY/CONVULSIONS</td>
|
||
<td>
|
||
<input type="radio" name="epilepsy" id="radio1" value="1" <?php if ($emp_health_assesment->epilepsy==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="epilepsy" id="radio1" value="0" <?php if ($emp_health_assesment->epilepsy==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>SWELLING IN THE EXTREMITIES</td>
|
||
<td>
|
||
<input type="radio" name="swelling_extremities" id="radio1" value="1" <?php if ($emp_health_assesment->swelling_extremities==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="swelling_extremities" id="radio1" value="0" <?php if ($emp_health_assesment->swelling_extremities==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>ALLERGIES</td>
|
||
<td>
|
||
<input type="radio" name="allergies" id="radio1" value="1" <?php if ($emp_health_assesment->allergies==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="allergies" id="radio1" value="0" <?php if ($emp_health_assesment->allergies==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
</table>
|
||
</div>
|
||
<div class="col-md-6">
|
||
<label></label>
|
||
<table class="col-md-6">
|
||
<tr>
|
||
<th>Condition</th>
|
||
<th>Yes</th>
|
||
<th>No</th>
|
||
</tr>
|
||
<tr>
|
||
<td>BACK PAIN</td>
|
||
<td>
|
||
<input type="radio" name="back_pain" id="radio1" value="1" <?php if ($emp_health_assesment->back_pain==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="back_pain" id="radio1" value="0" <?php if ($emp_health_assesment->back_pain==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>PAIN ON URINATION</td>
|
||
<td>
|
||
<input type="radio" name="pain_urination" id="radio1" value="1" <?php if ($emp_health_assesment->pain_urination==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="pain_urination" id="radio1" value="0" <?php if ($emp_health_assesment->pain_urination==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>CHANGE IN BOWEL HABITS</td>
|
||
<td>
|
||
<input type="radio" name="change_bowel_habit" id="radio1" value="1" <?php if ($emp_health_assesment->change_bowel_habit==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="change_bowel_habit" id="radio1" value="0" <?php if ($emp_health_assesment->change_bowel_habit==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>INCREASED THIRST</td>
|
||
<td>
|
||
<input type="radio" name="increased_thirst" id="radio1" value="1" <?php if ($emp_health_assesment->increased_thirst==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="increased_thirst" id="radio1" value="0" <?php if ($emp_health_assesment->increased_thirst==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>PERSISTENT SORES/LUMPS</td>
|
||
<td>
|
||
<input type="radio" name="persistent_lumps" id="radio1" value="1" <?php if ($emp_health_assesment->persistent_lumps==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="persistent_lumps" id="radio1" value="0" <?php if ($emp_health_assesment->persistent_lumps==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>INFECTIOUS DISEASE</td>
|
||
<td>
|
||
<input type="radio" name="infectious_disease" id="radio1" value="1" <?php if ($emp_health_assesment->infectious_disease==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="infectious_disease" id="radio1" value="0" <?php if ($emp_health_assesment->infectious_disease==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>CANCER</td>
|
||
<td>
|
||
<input type="radio" name="cancer" id="radio1" value="1" <?php if ($emp_health_assesment->cancer==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="cancer" id="radio1" value="0" <?php if ($emp_health_assesment->cancer==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>ANY OTHER PHYSICAL DISABILITY</td>
|
||
<td>
|
||
<input type="radio" name="other_disability" id="radio1" value="1" <?php if ($emp_health_assesment->other_disability==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="other_disability" id="radio1" value="0" <?php if ($emp_health_assesment->other_disability==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
</table>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-6">
|
||
<label>TURBERCULOSIS QUESTIONNAIRE<br>Indicate if you have been experiencing the following conditions:</label>
|
||
<table class="col-md-6">
|
||
<tr>
|
||
<th>Condition</th>
|
||
<th>Yes</th>
|
||
<th>No</th>
|
||
</tr>
|
||
<tr>
|
||
<td>PERSISTENT COUGH FOR < 3 WEEKS</td>
|
||
<td>
|
||
<input type="radio" name="cough_3_weeks" id="radio1" value="1" <?php if ($emp_health_assesment->cough_3_weeks==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="cough_3_weeks" id="radio1" value="0" <?php if ($emp_health_assesment->cough_3_weeks==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>BLOOD IN THE SPUTUM</td>
|
||
<td>
|
||
<input type="radio" name="blood_sputum" id="radio1" value="1" <?php if ($emp_health_assesment->blood_sputum==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="blood_sputum" id="radio1" value="0" <?php if ($emp_health_assesment->blood_sputum==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>SHORTNESS OF BREATH</td>
|
||
<td>
|
||
<input type="radio" name="shortness_breath" id="radio1" value="1" <?php if ($emp_health_assesment->shortness_breath==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="shortness_breath" id="radio1" value="0" <?php if ($emp_health_assesment->shortness_breath==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>NIGHT SWEATS</td>
|
||
<td>
|
||
<input type="radio" name="night_sweat" id="radio1" value="1" <?php if ($emp_health_assesment->night_sweat==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="night_sweat" id="radio1" value="0" <?php if ($emp_health_assesment->night_sweat==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>CHEST PAIN</td>
|
||
<td>
|
||
<input type="radio" name="chest_pain" id="radio1" value="1" <?php if ($emp_health_assesment->chest_pain==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="chest_pain" id="radio1" value="0" <?php if ($emp_health_assesment->chest_pain==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
</table>
|
||
</div>
|
||
<div class="col-md-6">
|
||
<label></label>
|
||
<table class="col-md-6">
|
||
<tr>
|
||
<th>Condition</th>
|
||
<th>Yes</th>
|
||
<th>No</th>
|
||
</tr>
|
||
<tr>
|
||
<td>UNEXPLAINED WEIGHT LOSS</td>
|
||
<td>
|
||
<input type="radio" name="unexplained_weight_loss" id="radio1" value="1" <?php if ($emp_health_assesment->unexplained_weight_loss==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="unexplained_weight_loss" id="radio1" value="0" <?php if ($emp_health_assesment->unexplained_weight_loss==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>LOSS OF APPETITE</td>
|
||
<td>
|
||
<input type="radio" name="appetite_loss" id="radio1" value="1" <?php if ($emp_health_assesment->appetite_loss==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="appetite_loss" id="radio1" value="0" <?php if ($emp_health_assesment->appetite_loss==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>HOARSENESS</td>
|
||
<td>
|
||
<input type="radio" name="hoarseness" id="radio1" value="1" <?php if ($emp_health_assesment->hoarseness==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="hoarseness" id="radio1" value="0" <?php if ($emp_health_assesment->hoarseness==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>INCREASED THIRST</td>
|
||
<td>
|
||
<input type="radio" name="thirst_increase" id="radio1" value="1" <?php if ($emp_health_assesment->thirst_increase==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="thirst_increase" id="radio1" value="0" <?php if ($emp_health_assesment->thirst_increase==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>FATIGUE</td>
|
||
<td>
|
||
<input type="radio" name="fatigue" id="radio1" value="1" <?php if ($emp_health_assesment->fatigue==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="fatigue" id="radio1" value="0" <?php if ($emp_health_assesment->fatigue==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>FEVER</td>
|
||
<td>
|
||
<input type="radio" name="fever" id="radio1" value="1" <?php if ($emp_health_assesment->fever==1) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
<td>
|
||
<input type="radio" name="fever" id="radio1" value="0" <?php if ($emp_health_assesment->fever==0) {
|
||
echo "checked"; } ?>/>
|
||
</td>
|
||
</tr>
|
||
</table>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Have you had a positive PPD reading?'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="positive_ppdYES" name="positive_ppd" value="1" <?php if ($emp_health_assesment->positive_ppd==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="positive_ppdYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="positive_ppdNO" name="positive_ppd" value="0" <?php if ($emp_health_assesment->positive_ppd==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="positive_ppdNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6 ppdExplain" <?php if ($emp_health_assesment->positive_ppd ==0 ) {?> style="display:none" <?php } ?>>
|
||
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="ppd_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('ppd_explain');
|
||
}
|
||
if (!empty($emp_health_assesment->ppd_explain)) {
|
||
echo $emp_health_assesment->ppd_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
</div>
|
||
<script>
|
||
$('input[name=positive_ppd]').on('change', function() {
|
||
var value = $(this).val();
|
||
if(value > 0){
|
||
$(".ppdExplain").show();
|
||
}else{
|
||
$(".ppdExplain").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Are you under the care of a physician?'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="under_careYES" name="under_care" value="1" <?php if ($emp_health_assesment->under_care==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="under_careYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="under_careNO" name="under_care" value="0" <?php if ($emp_health_assesment->under_care==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="under_careNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6 under_care_explain" <?php if ($emp_health_assesment->under_care ==0 ) {?> style="display:none" <?php } ?>>
|
||
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="under_care_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('under_care_explain');
|
||
}
|
||
if (!empty($emp_health_assesment->under_care_explain)) {
|
||
echo $emp_health_assesment->under_care_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
</div>
|
||
<script>
|
||
$('input[name=under_care]').on('change', function() {
|
||
var value = $(this).val();
|
||
if(value > 0){
|
||
$(".under_care_explain").show();
|
||
}else{
|
||
$(".under_care_explain").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Do you take depressants, stimulants, narcotic drugs that alter your behavior?'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="change_behaviourYES" name="change_behaviour" value="1" <?php if ($emp_health_assesment->change_behaviour==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="change_behaviourYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="change_behaviourNO" name="change_behaviour" value="0" <?php if ($emp_health_assesment->change_behaviour==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="change_behaviourNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6 change_behaviour_explain" <?php if ($emp_health_assesment->change_behaviour ==0 ) {?> style="display:none" <?php } ?>>
|
||
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="change_behaviour_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('change_behaviour_explain');
|
||
}
|
||
if (!empty($emp_health_assesment->change_behaviour_explain)) {
|
||
echo $emp_health_assesment->change_behaviour_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
</div>
|
||
<script>
|
||
$('input[name=change_behaviour]').on('change', function() {
|
||
var value = $(this).val();
|
||
if(value > 0){
|
||
$(".change_behaviour_explain").show();
|
||
}else{
|
||
$(".change_behaviour_explain").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Do you take prescription medications? '); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="prescription_medicationsYES" name="prescription_medications" value="1"<?php if ($emp_health_assesment->prescription_medications==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="prescription_medicationsYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="prescription_medicationsNO" name="prescription_medications" value="0" <?php if ($emp_health_assesment->prescription_medications==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="prescription_medicationsNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6 prescription_medications_explain" <?php if ($emp_health_assesment->prescription_medications ==0 ) {?> style="display:none" <?php } ?>>
|
||
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="prescription_medications_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('prescription_medications_explain');
|
||
}
|
||
if (!empty($emp_health_assesment->prescription_medications_explain)) {
|
||
echo $emp_health_assesment->prescription_medications_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
</div>
|
||
<script>
|
||
$('input[name=prescription_medications]').on('change', function() {
|
||
var value = $(this).val();
|
||
if(value > 0){
|
||
$(".prescription_medications_explain").show();
|
||
}else{
|
||
$(".prescription_medications_explain").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('If required in your position, would you be willing to have screening test for drugs/alcohol done on your blood /urine as a condition for employment? '); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="screening_testYES" name="screening_test" value="1" <?php if ($emp_health_assesment->screening_test==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="screening_testYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="screening_testNO" name="screening_test" value="0" <?php if ($emp_health_assesment->screening_test==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="screening_testNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6 screening_test_explain" <?php if ($emp_health_assesment->screening_test ==0 ) {?> style="display:none" <?php } ?>>
|
||
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="screening_test_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('screening_test_explain');
|
||
}
|
||
if (!empty($emp_health_assesment->screening_test_explain)) {
|
||
echo $emp_health_assesment->screening_test_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
</div>
|
||
<script>
|
||
$('input[name=screening_test]').on('change', function() {
|
||
var value = $(this).val();
|
||
if(value > 0){
|
||
$(".screening_test_explain").show();
|
||
}else{
|
||
$(".screening_test_explain").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Have you had any operations or hospitalization for illnesses past 5 years?'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="past_illnessYES" name="past_illness" value="1" <?php if ($emp_health_assesment->past_illness==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="past_illnessYES">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="past_illnessNO" name="past_illness" value="0" <?php if ($emp_health_assesment->past_illness==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="past_illnessNO">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-6 past_illness_explain" <?php if ($emp_health_assesment->past_illness ==0 ) {?> style="display:none" <?php } ?>>
|
||
<label for="exampleInputEmail1" ><?php echo lang('Explain'); ?></label>
|
||
<input type="text" class="form-control" name="past_illness_explain" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('past_illness_explain');
|
||
}
|
||
if (!empty($emp_health_assesment->past_illness_explain)) {
|
||
echo $emp_health_assesment->past_illness_explain;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
</div>
|
||
<script>
|
||
$('input[name=past_illness]').on('change', function() {
|
||
var value = $(this).val();
|
||
if(value > 0){
|
||
$(".past_illness_explain").show();
|
||
}else{
|
||
$(".past_illness_explain").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<div class="row">
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Name of Physician'); ?></label>
|
||
<input type="text" class="form-control" name="name_of_physician" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('name_of_physician');
|
||
}
|
||
if (!empty($emp_health_assesment->name_of_physician)) {
|
||
echo $emp_health_assesment->name_of_physician;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
<div class="form-group col-md-6">
|
||
<label for="exampleInputEmail1"><?php echo lang('Telephone'); ?></label>
|
||
<input type="text" class="form-control" name="tel_of_physician" onkeypress="return isNumberKey(event)" onkeyup="USformatPhoneNumber(this.value,this)" onblur="USformatPhoneNumber(this.value,this)" value='<?php
|
||
if (!empty($setval)) {
|
||
echo set_value('tel_of_physician');
|
||
}
|
||
if (!empty($emp_health_assesment->tel_of_physician)) {
|
||
echo $emp_health_assesment->tel_of_physician;
|
||
}
|
||
?>' placeholder="">
|
||
</div>
|
||
<div class="form-group col-md-12">
|
||
<button type="submit" name="submit" class="btn btn-info" onclick="return validateForm();"><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
</form>
|
||
</div>
|
||
<div class="tab-pane fade <?php if($tab==4) {?> active in show <?php } ?>" id="tab10" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<form role="form" action="<?php echo base_url(); ?>caregivers/saveHapatitisB" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<?php $hbForm=json_decode($nurse->hb_form);
|
||
//pr($nurse);die;
|
||
?>
|
||
<input type="hidden" name="form_tab_status" value="10">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<input type="hidden" name="form_status" value="10">
|
||
<input type="hidden" name="form_mode" value="<?php if($nurse->form_status>0) echo 'Edit'; else echo 'Add'; ?>">
|
||
<div class="row">
|
||
<div class="form-group col-md-5">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Name'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->fname)) {
|
||
echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
<div class="form-group col-md-5">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('DOB'); ?></label>
|
||
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
|
||
if (!empty($nurse->fname)) {
|
||
echo $nurse->dob;
|
||
}
|
||
?>' disabled>
|
||
</div>
|
||
|
||
<div class="form-group col-md-2 mt-2 mt-25">
|
||
<!-- <a class="btn btn-primary file-upload" href="<?php echo base_url(); ?>uploads/hb.pdf" target="_blank" download> Download</a> -->
|
||
</div>
|
||
|
||
</div>
|
||
<div class="row">
|
||
<p> I <?= $nurse->fname." ".$nurse->mid_name." ".$nurse->lname ?> , have been informed of the complication / side effects of receiving Hepatitis B vaccine and I choose to have the vaccine administered to me.</p>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Allergies'); ?></label>
|
||
<input type="text" class="form-control" name="Allergies" id="exampleInputEmail1" value='<?php
|
||
if (!empty($hbForm->Allergies)) {
|
||
echo $hbForm->Allergies;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Date of Exposure'); ?></label>
|
||
<input type="date" class="form-control" name="date_of_exposure" id="exampleInputEmail1" value='<?php
|
||
if (!empty($hbForm->date_of_exposure)) {
|
||
echo $hbForm->date_of_exposure;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
<div class="form-group col-md-4">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Location'); ?></label>
|
||
<input type="text" class="form-control" name="location" id="exampleInputEmail1" value='<?php
|
||
if (!empty($hbForm->location)) {
|
||
echo $hbForm->location;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Type of exposure'); ?></label>
|
||
<input type="text" class="form-control" name="type_of_exposure" id="exampleInputEmail1" value='<?php
|
||
if (!empty($hbForm->type_of_exposure)) {
|
||
echo $hbForm->type_of_exposure;
|
||
}
|
||
?>' required>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Incident Report Completed'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="physicaldefectsyes" name="incident_report" value="1" <?php if ($hbForm->incident_report==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="physicaldefectsyes">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="physicaldefectsno" name="incident_report" value="0" <?php if ($hbForm->incident_report==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="physicaldefectsno">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-12">
|
||
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Worker’s Compensation Report Completed'); ?></label>
|
||
<div class="col-md-6">
|
||
<div class="row">
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="injuredyes" name="report_completed" value="1" <?php if ($hbForm->report_completed==1) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="injuredyes">Yes
|
||
</label>
|
||
</div>
|
||
<div class="form-check width-80">
|
||
<input class="form-check-input" type="radio" id="injuredno" name="report_completed" value="0" <?php if ($hbForm->report_completed==0) {
|
||
echo "checked"; } ?>>
|
||
<label class="form-check-label" for="injuredno">No
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-12">
|
||
<table class="table-responsive">
|
||
<tr>
|
||
<td>Hepatitis B Vaccine</td>
|
||
<td>TYPE</td>
|
||
<td>DATE</td>
|
||
<td>DOSE</td>
|
||
<td>SITE</td>
|
||
</tr>
|
||
|
||
<tr>
|
||
<td>Initial Dose</td>
|
||
<td><input type="text" name="Initial_Dose_Type" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Type)) {
|
||
echo $hbForm->Initial_Dose_Type;
|
||
}
|
||
?>'></td>
|
||
<td><input type="date" name="Initial_Dose_Date" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Date)) {
|
||
echo $hbForm->Initial_Dose_Date;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose)) {
|
||
echo $hbForm->Initial_Dose;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose_Site" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Site)) {
|
||
echo $hbForm->Initial_Dose_Site;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
<tr>
|
||
<td>Second Dose</td>
|
||
<td><input type="text" name="Initial_Dose_Type2" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Type2)) {
|
||
echo $hbForm->Initial_Dose_Type2;
|
||
}
|
||
?>'></td>
|
||
<td><input type="date" name="Initial_Dose_Date2" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Type2)) {
|
||
echo $hbForm->Initial_Dose_Type2;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose2" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose2)) {
|
||
echo $hbForm->Initial_Dose2;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose_Site2" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Site2)) {
|
||
echo $hbForm->Initial_Dose_Site2;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
<tr>
|
||
<td>Third Dose</td>
|
||
<td><input type="text" name="Initial_Dose_Type3" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Type3)) {
|
||
echo $hbForm->Initial_Dose_Type3;
|
||
}
|
||
?>'></td>
|
||
<td><input type="date" name="Initial_Dose_Date3" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Type3)) {
|
||
echo $hbForm->Initial_Dose_Type3;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose3" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose3)) {
|
||
echo $hbForm->Initial_Dose3;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose_Site3" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Site3)) {
|
||
echo $hbForm->Initial_Dose_Site3;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
<tr>
|
||
<td>Booster Dose</td>
|
||
<td><input type="text" name="Initial_Dose_Type4" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Type4)) {
|
||
echo $hbForm->Initial_Dose_Type4;
|
||
}
|
||
?>'></td>
|
||
<td><input type="date" name="Initial_Dose_Date4" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Type4)) {
|
||
echo $hbForm->Initial_Dose_Type4;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose4" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose4)) {
|
||
echo $hbForm->Initial_Dose4;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="Initial_Dose_Site4" class="form-control" value='<?php
|
||
if (!empty($hbForm->Initial_Dose_Site4)) {
|
||
echo $hbForm->Initial_Dose_Site4;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
</table>
|
||
</div>
|
||
<div class="col-md-12">
|
||
<label><?php echo lang('Lab Work Performed'); ?></label>
|
||
<table class="table-responsive">
|
||
<tr>
|
||
<td>DATE</td>
|
||
<td>TYPE</td>
|
||
<td>RESULTS</td>
|
||
<td>ACTION TAKEN</td>
|
||
</tr>
|
||
|
||
<tr>
|
||
|
||
<td><input type="date" name="lab_date1" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_date1)) {
|
||
echo $hbForm->lab_date1;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_type1" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_type1)) {
|
||
echo $hbForm->lab_type1;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_result1" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_result1)) {
|
||
echo $hbForm->lab_result1;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_action1" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_action1)) {
|
||
echo $hbForm->lab_action1;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
<tr><td><input type="date" name="lab_date2" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_date2)) {
|
||
echo $hbForm->lab_date2;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_type2" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_type2)) {
|
||
echo $hbForm->lab_type2;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_result2" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_result2)) {
|
||
echo $hbForm->lab_result2;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_action2" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_action2)) {
|
||
echo $hbForm->lab_action2;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
<tr>
|
||
<td><input type="date" name="lab_date3" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_date3)) {
|
||
echo $hbForm->lab_date3;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_type3" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_type3)) {
|
||
echo $hbForm->lab_type3;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_result3" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_result3)) {
|
||
echo $hbForm->lab_result3;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_action3" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_action3)) {
|
||
echo $hbForm->lab_action3;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
<tr>
|
||
|
||
<td><input type="date" name="lab_date4" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_date4)) {
|
||
echo $hbForm->lab_date4;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_type4" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_type4)) {
|
||
echo $hbForm->lab_type4;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_result4" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_result4)) {
|
||
echo $hbForm->lab_result4;
|
||
}
|
||
?>'></td>
|
||
<td><input type="text" name="lab_action4" class="form-control" value='<?php
|
||
if (!empty($hbForm->lab_action4)) {
|
||
echo $hbForm->lab_action4;
|
||
}
|
||
?>'></td>
|
||
</tr>
|
||
</table>
|
||
</div>
|
||
</div>
|
||
<div class="form-group col-md-12">
|
||
<button type="submit" name="submit" class="btn btn-info" onclick="return validateForm();"><?php echo lang('submit'); ?></button>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<div class="tab-pane fade <?php if($tab==5) {?> active in show <?php } ?>" id="ACCEPTENCE" role="tabpanel" aria-labelledby="ACCEPTENCE-tab">
|
||
<form action="<?php echo base_url(); ?>caregivers/saveApproval" onsubmit="return validateAcceptance();" method="post">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="caregiver_id" value="<?php echo $nurse->caregiver_table_id; ?>">
|
||
<div class="col-md-12">
|
||
<table class="table verification-table">
|
||
<thead>
|
||
<tr>
|
||
<th scope="col">Field</th>
|
||
<th scope="col">Data</th>
|
||
<th scope="col">Action</th>
|
||
</tr>
|
||
</thead>
|
||
<tbody>
|
||
<tr><td colspan="3" class="verification-tab">Basic Info</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Name</td>
|
||
<td class="verification-label-value"><?php echo $nurse->fname.''.$nurse->lname; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Mobile Number</td>
|
||
<td class="verification-label-value"><?php echo $nurse->phone; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Mobile_Number]" value="Mobile Number">
|
||
<textarea name="varify_data[Mobile_Number]" style="display: none;"><?php echo $nurse->phone; ?></textarea>
|
||
<input type="hidden" name="varify_file[Mobile_Number]" value="">
|
||
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Email</td>
|
||
<td class="verification-label-value"><?php echo $nurse->email; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Email]" value="Email">
|
||
<textarea name="varify_data[Email]" style="display: none;"><?php echo $nurse->email; ?></textarea>
|
||
<input type="hidden" name="varify_file[Email]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Qualification type</td>
|
||
<td class="verification-label-value"><?php echo $nurse->qualification; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[qualification]" value="Qualification">
|
||
<textarea name="varify_data[qualification]" style="display: none;"><?php echo $nurse->qualification; ?></textarea>
|
||
<input type="hidden" name="varify_file[qualification]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Total years of experience</td>
|
||
<td class="verification-label-value"><?php echo $nurse->years_of_exp; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Total_years_of experience]" value="Total years of experience">
|
||
<textarea name="varify_data[Total_years_of]" style="display: none;"><?php echo $nurse->years_of_exp; ?></textarea>
|
||
<input type="hidden" name="varify_file[Total_years_of]" value="">
|
||
</td>
|
||
</tr>
|
||
|
||
<tr><td colspan="3" class="verification-tab">Personal Info</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Gender</td>
|
||
<td class="verification-label-value"><?php echo $nurse->gender; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Marital Status</td>
|
||
<td class="verification-label-value"><?php echo $nurse->marital_status; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Dependents</td>
|
||
<td class="verification-label-value"><?php echo $nurse->dependents; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Dependents]" value="dependents">
|
||
<textarea name="varify_data[Dependents]" style="display: none;"><?php echo $nurse->dependents; ?></textarea>
|
||
<input type="hidden" name="varify_file[Dependents]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Date of Birth</td>
|
||
<td class="verification-label-value"><?php echo $nurse->dob; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[dob]" value="dependents">
|
||
<textarea name="varify_data[dob]" style="display: none;"><?php echo $nurse->dob; ?></textarea>
|
||
<input type="hidden" name="varify_file[dob]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Soc Sec</td>
|
||
<td class="verification-label-value"><?php echo $nurse->soc_sec; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[soc_sec]" value="soc_sec">
|
||
<textarea name="varify_data[soc_sec]" style="display: none;"><?php echo $nurse->soc_sec; ?></textarea>
|
||
<input type="hidden" name="varify_file[soc_sec]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Country of Birth</td>
|
||
<td class="verification-label-value"><?php echo $nurse->country_of_birth; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[country_of_birth]" value="country_of_birth">
|
||
<textarea name="varify_data[country_of_birth]" style="display: none;"><?php echo $nurse->country_of_birth; ?></textarea>
|
||
<input type="hidden" name="varify_file[country_of_birth]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Ethnicity</td>
|
||
<td class="verification-label-value"><?php echo $nurse->ethnicity; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[ethnicity]" value="country_of_birth">
|
||
<textarea name="varify_data[ethnicity]" style="display: none;"><?php echo $nurse->ethnicity; ?></textarea>
|
||
<input type="hidden" name="varify_file[ethnicity]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Height (feet/inches)</td>
|
||
<td class="verification-label-value"><?php echo $nurse->height; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Weight ()</td>
|
||
<td class="verification-label-value"><?php echo $nurse->weight; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Eye Color</td>
|
||
<td class="verification-label-value"><?php echo $nurse->eye_color; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Hair Color</td>
|
||
<td class="verification-label-value"><?php echo $nurse->hair_color; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Primary Languages Spoke</td>
|
||
<td class="verification-label-value"><?php echo $nurse->primary_langualge; ?></td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr><td colspan="3" class="verification-tab">Contact Info</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Permanent Address</td>
|
||
<td class="verification-label-value"><?php echo $nurse->address1.','.$nurse->direction1.','.$nurse->state1_name.','.$nurse->county1.','.$nurse->zipcode1; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Permanent_Address]" value="Permanent_Address">
|
||
<textarea name="varify_data[Permanent_Address]" style="display: none;"><?php echo $nurse->address1.','.$nurse->direction1.','.$nurse->state1_name.','.$nurse->county1.','.$nurse->zipcode1; ?></textarea>
|
||
<input type="hidden" name="varify_file[Permanent_Address]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">State Verification</td>
|
||
<td class="verification-label-value"><?php echo $nurse->state1_name; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[state_verification]" value="true">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Alternate Mailing Address</td>
|
||
<td class="verification-label-value"><?php echo $nurse->address2.','.$nurse->direction2.','.$nurse->state2_name.','.$nurse->county2.','.$nurse->zipcode2; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Alternate_Mailing_Address]" value="Alternate Mailing Address">
|
||
<textarea name="varify_data[Alternate_Mailing_Address]" style="display: none;"><?php echo $nurse->address2.','.$nurse->direction2.','.$nurse->state2_name.','.$nurse->county2.','.$nurse->zipcode2; ?></textarea>
|
||
<input type="hidden" name="varify_file[Alternate_Mailing_Address]" value="">
|
||
</td>
|
||
</tr>
|
||
|
||
<tr>
|
||
<td class="verification-label">Alternative Mobile No.</td>
|
||
<td class="verification-label-value"><?php echo $nurse->phone2; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Alternative_Mobile_No]" value="Alternative Mobile No">
|
||
<textarea name="varify_data[Alternative_Mobile_No]" style="display: none;"><?php echo $nurse->phone2; ?></textarea>
|
||
<input type="hidden" name="varify_file[Alternative_Mobile_No]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Other Contact</td>
|
||
<td class="verification-label-value"><?php echo $nurse->other_contact; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Other_Contact]" value="Other Contact">
|
||
<textarea name="varify_data[Other_Contact]" style="display: none;"><?php echo $nurse->other_contact; ?></textarea>
|
||
<input type="hidden" name="varify_file[Other_Contact]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Alternative Email</td>
|
||
<td class="verification-label-value"><?php echo $nurse->alternative_email; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Alternative_Email]" value="Alternative Email">
|
||
<textarea name="varify_data[Alternative_Email]" style="display: none;"><?php echo $nurse->alternative_email; ?></textarea>
|
||
<input type="hidden" name="varify_file[Alternative_Email]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Preferred Contact Method</td>
|
||
<td class="verification-label-value"><?php echo $nurse->preferred_contact; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Preferred_Contact_Method]" value="Preferred Contact Method">
|
||
<textarea name="varify_data[Preferred_Contact_Method]" style="display: none;"><?php echo $nurse->preferred_contact; ?></textarea>
|
||
<input type="hidden" name="varify_file[Preferred_Contact_Method]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr><td colspan="3" class="verification-tab">Basic Documents</td></tr>
|
||
<tr>
|
||
<td class="verification-label">School Certificate Verification </td>
|
||
<td class="verification-label-value">
|
||
</td class="verification-label-value">
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[school_certificate]" value="true">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Photo </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_PHOTOCODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_PHOTOCODE_][0]; ?>">View</a>
|
||
</td class="verification-label-value">
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Photo]" value="Photo">
|
||
<textarea name="varify_data[Photo]" style="display: none;"><?php echo $documentsrem[_DOC_PHOTOCODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Photo]" value="<?php echo $documentsarr[_DOC_PHOTOCODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Citizen Documentation </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_CTZCODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_CTZCODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Citizenship_Document]" value="Citizenship Document">
|
||
<textarea name="varify_data[Citizenship_Document]" style="display: none;"><?php echo $documentsrem[_DOC_CTZCODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Citizenship_Document]" value="<?php echo $documentsarr[_DOC_CTZCODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Social Security Card </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_SSCCODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_SSCCODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Social_Security_Card]" value="Citizenship Document">
|
||
<textarea name="varify_data[Social_Security_Card]" style="display: none;"><?php echo $documentsrem[_DOC_SSCCODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Social_Security_Card]" value="<?php echo $documentsarr[_DOC_SSCCODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">State or Federal issued ID </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_SFICODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_SFICODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[State_or_Federal_issued_ID]" value="State or Federal issued ID ">
|
||
<textarea name="varify_data[State_or_Federal_issued_ID]" style="display: none;"><?php echo $documentsrem[_DOC_SFICODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[State_or_Federal_issued_ID]" value="<?php echo $documentsarr[_DOC_SFICODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Malpractice Insurance Policy </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_MICCODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_MICCODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Malpractice_Insurance_Policy]" value="Malpractice Insurance Policy">
|
||
<textarea name="varify_data[Malpractice_Insurance_Policy]" style="display: none;"><?php echo $documentsrem[_DOC_MICCODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Malpractice_Insurance_Policy]" value="<?php echo $documentsarr[_DOC_MICCODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Resume </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_RESUMECODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_RESUMECODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Resume]" value="Resume">
|
||
<textarea name="varify_data[Resume]" style="display: none;"><?php echo $documentsrem[_DOC_RESUMECODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Resume]" value="<?php echo $documentsarr[_DOC_RESUMECODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">NPI Document </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_NPICODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_NPICODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[NPI_Document]" value="NPI Document">
|
||
<textarea name="varify_data[NPI_Document]" style="display: none;"><?php echo $documentsrem[_DOC_NPICODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[NPI_Document]" value="<?php echo $documentsarr[_DOC_NPICODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr><td colspan="3" class="verification-tab">Medical Documents</td></tr>
|
||
<!-- <tr>
|
||
<td class="verification-label">Rubella </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_RUBELLACODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_RUBELLACODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Rubella]" value="Rubella">
|
||
<textarea name="varify_data[Rubella]" style="display: none;"><?php echo $documentsrem[_DOC_RUBELLACODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Rubella]" value="<?php echo $documentsarr[_DOC_RUBELLACODE_][0]; ?>">
|
||
</td>
|
||
</tr> -->
|
||
<!-- <tr>
|
||
<td class="verification-label">Ruboella </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_RUBOELLACODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo $documentsarr[_DOC_RUBOELLACODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Ruboella]" value="Ruboella">
|
||
<textarea name="varify_data[Ruboella]" style="display: none;"><?php echo $documentsrem[_DOC_RUBOELLACODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Ruboella]" value="<?php echo $documentsarr[_DOC_RUBOELLACODE_][0]; ?>">
|
||
</td>
|
||
</tr> -->
|
||
<tr>
|
||
<td class="verification-label">Annual Employee Health </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_EHA_CODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_EHA_CODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Annual_Employee_Health]" value="Annual Employee Health">
|
||
<textarea name="varify_data[Annual_Employee_Health]" style="display: none;"><?php echo $documentsrem[_DOC_EHA_CODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Annual_Employee_Health]" value="<?php echo $documentsarr[_DOC_EHA_CODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<!-- <td class="verification-label">PPD </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_PPDCODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_PPDCODE_][0]; ?>">View</a>
|
||
</td> -->
|
||
<!-- <td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[PPD]" value="PPD">
|
||
<textarea name="varify_data[PPD]" style="display: none;"><?php echo $documentsrem[_DOC_PPDCODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[PPD]" value="<?php echo $documentsarr[_DOC_PPDCODE_][0]; ?>">
|
||
</td> -->
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Drug Screen </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_DRUG_SCREENINGCODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_DRUG_SCREENINGCODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Drug_Screen]" value="Drug Screen">
|
||
<textarea name="varify_data[Drug_Screen]" style="display: none;"><?php echo $documentsrem[_DOC_DRUG_SCREENINGCODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Drug_Screen]" value="<?php echo $documentsarr[_DOC_DRUG_SCREENINGCODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Flu Vaccine </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_FLU_VACCINECODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_FLU_VACCINECODE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Flu_Vaccine]" value="Flu Vaccine">
|
||
<textarea name="varify_data[Flu_Vaccine]" style="display: none;"><?php echo $documentsrem[_DOC_FLU_VACCINECODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Flu_Vaccine]" value="<?php echo $documentsarr[_DOC_FLU_VACCINECODE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Covid Report </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_COVID_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_COVID_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Covid_Report ]" value="Covid Report">
|
||
<textarea name="varify_data[Covid_Report]" style="display: none;"><?php echo $documentsrem[_DOC_COVID_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Covid_Report]" value="<?php echo $documentsarr[_DOC_COVID_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">CPR Report</td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_CPR_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_CPR_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[CPR_Report ]" value="CPR Report">
|
||
<textarea name="varify_data[CPR_Report]" style="display: none;"><?php echo $documentsrem[_DOC_CPR_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[CPR_Report]" value="<?php echo $documentsarr[_DOC_CPR_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<!-- <td class="verification-label">Chest X-ray </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_CHEST_X_RAYCODE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_CHEST_X_RAYCODE_][0]; ?>">View</a>
|
||
</td> -->
|
||
<!-- <td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Chest_X_ray]" value="Chest X-ray">
|
||
<textarea name="varify_data[Chest_X_ray]" style="display: none;"><?php echo $documentsrem[_DOC_CHEST_X_RAYCODE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Chest_X_ray]" value="<?php echo $documentsarr[_DOC_CHEST_X_RAYCODE_][0]; ?>">
|
||
</td> -->
|
||
</tr>
|
||
<tr><td colspan="3" class="verification-tab">Licenses & Certifications</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Licence </td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_TRAINING_LICENCE_][0]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_TRAINING_LICENCE_][0]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Licence]" value="Licence">
|
||
<textarea name="varify_data[Licence]" style="display: none;"><?php echo $documentsrem[_DOC_TRAINING_LICENCE_][0]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Licence]" value="<?php echo $documentsarr[_DOC_TRAINING_LICENCE_][0]; ?>">
|
||
</td>
|
||
</tr>
|
||
<!-- <tr><td colspan="3" class="verification-tab">Training Documents</td></tr> -->
|
||
<?php for($i=0;$i<$traing_doc_count;$i++){ ?>
|
||
<tr>
|
||
<td class="verification-label">Aditional Documents</td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_TRAININGCODE_][$i]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_TRAININGCODE_][$i]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Training_Documents<?php echo $i;?>]" value="Training Documents<?php echo $i;?>">
|
||
<textarea name="varify_data[Training_Documents<?php echo $i;?>]" style="display: none;"><?php echo $documentsrem[_DOC_TRAININGCODE_][$i]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Training_Documents<?php echo $i;?>]" value="<?php echo $documentsarr[_DOC_TRAININGCODE_][$i]; ?>">
|
||
</td>
|
||
</tr>
|
||
<?php } ?>
|
||
<tr><td colspan="3" class="verification-tab">Other Documents</td></tr>
|
||
<?php for($i=0;$i<$other_doc_count;$i++){ ?>
|
||
<tr>
|
||
<td class="verification-label">Documents Details</td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_DOC_OTHERCODE_][$i]; ?>
|
||
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_OTHERCODE_][$i]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Other_Documents<?php echo $i;?>]" value="Other Documents<?php echo $i;?>">
|
||
<textarea name="varify_data[Other_Documents<?php echo $i;?>]" style="display: none;"><?php echo $documentsrem[_DOC_OTHERCODE_][$i]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Other_Documents<?php echo $i;?>]" value="<?php echo $documentsarr[_DOC_OTHERCODE_][$i]; ?>">
|
||
</td>
|
||
</tr>
|
||
<?php } ?>
|
||
<tr><td colspan="3" class="verification-tab">Employment Info</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Availability(Borough)</td>
|
||
<td class="verification-label-value"><?php echo $nurse->avail_borough; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Availability_Borough]" value="Availability(Borough)">
|
||
<textarea name="varify_data[Availability_Borough]" style="display: none;"><?php echo $nurse->avail_borough; ?></textarea>
|
||
<input type="hidden" name="varify_file[Availability_Borough]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Availability(Time Slot)</td>
|
||
<td class="verification-label-value"><?php echo $nurse->avail_time_slot; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Availability_Time_Slot]" value="Availability(Time Slot)">
|
||
<textarea name="varify_data[Availability_Time_Slot]" style="display: none;"><?php echo $nurse->avail_time_slot; ?></textarea>
|
||
<input type="hidden" name="varify_file[Availability_Time_Slot]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Availability(Stay)</td>
|
||
<td class="verification-label-value"><?php echo $nurse->availability_stay; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Availability_Stay]" value="Availability(Stay)">
|
||
<textarea name="varify_data[Availability_Stay]" style="display: none;"><?php echo $nurse->availability_stay; ?></textarea>
|
||
<input type="hidden" name="varify_file[Availability_Stay]" value="">
|
||
</td>
|
||
</tr>
|
||
<!-- <tr>
|
||
<td class="verification-label">Availability and other Notes</td>
|
||
<td class="verification-label-value"><?php echo $nurse->availability_note; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Availability_and_other_Notes]" value="Availability and other Notes">
|
||
<textarea name="varify_data[Availability_and_other_Notes]" style="display: none;"><?php echo $nurse->availability_note; ?></textarea>
|
||
<input type="hidden" name="varify_file[Availability_and_other_Notes]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Referral Source</td>
|
||
<td class="verification-label-value"><?php echo $nurse->ref_source; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Referral_Source]" value="Referral Source">
|
||
<textarea name="varify_data[Referral_Source]" style="display: none;"><?php echo $nurse->ref_source; ?></textarea>
|
||
<input type="hidden" name="varify_file[Referral_Source]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Profession</td>
|
||
<td class="verification-label-value"><?php echo $nurse->profesonal; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Profession]" value="Profession">
|
||
<textarea name="varify_data[Profession]" style="display: none;"><?php echo $nurse->profesonal; ?></textarea>
|
||
<input type="hidden" name="varify_file[Profession]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Employee Type</td>
|
||
<td class="verification-label-value"><?php echo $nurse->employee_type; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Employee_Type]" value="Employee Type">
|
||
<textarea name="varify_data[Employee_Type]" style="display: none;"><?php echo $nurse->employee_type; ?></textarea>
|
||
<input type="hidden" name="varify_file[Employee_Type]" value="">
|
||
</td>
|
||
</tr> -->
|
||
<tr>
|
||
<td class="verification-label">Application Date</td>
|
||
<td class="verification-label-value"><?php echo $nurse->application_date; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked"></td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Pre Employment Skill Competency</td>
|
||
<td class="verification-label-value"><?php echo $nurse->pre_emp_skill; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Pre_Employment_Skill_Competency]" value="Pre Employment Skill Competency">
|
||
<textarea name="varify_data[Pre_Employment_Skill_Competency]" style="display: none;"><?php echo $nurse->pre_emp_skill; ?></textarea>
|
||
<input type="hidden" name="varify_file[Pre_Employment_Skill_Competency]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">PCA Registry Number</td>
|
||
<td class="verification-label-value"><?php echo $nurse->PCA_Registry_Number; ?>
|
||
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[PCA_Registry_Number]" value="PCA Registry Number">
|
||
<textarea name="varify_data[PCA_Registry_Number]" style="display: none;"><?php echo $nurse->PCA_Registry_Number; ?></textarea>
|
||
<input type="hidden" name="varify_file[PCA_Registry_Number]" value="">
|
||
</td>
|
||
</tr>
|
||
<!-- <tr>
|
||
<td class="verification-label">NPI Number</td>
|
||
<td class="verification-label-value"><?php echo $nurse->NPI_Number; ?>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[NPI_Number]" value="NPI Number">
|
||
<textarea name="varify_data[NPI_Number]" style="display: none;"><?php echo $nurse->NPI_Number; ?></textarea>
|
||
<input type="hidden" name="varify_file[NPI_Number]" value="">
|
||
</td>
|
||
</tr> -->
|
||
|
||
<tr><td colspan="3" class="verification-tab">Reference</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Personal References Name</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Personal_References_Name; ?>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Personal_References_Name]" value="Personal References Name">
|
||
<textarea name="varify_data[Personal_References_Name]" style="display: none;"><?php echo $nurse->Personal_References_Name; ?></textarea>
|
||
<input type="hidden" name="varify_file[Personal_References_Name]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Personal References Address</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Personal_References_Address; ?>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Personal_References_Address]" value="Personal References Address">
|
||
<textarea name="varify_data[Personal_References_Address]" style="display: none;"><?php echo $nurse->Personal_References_Address; ?></textarea>
|
||
<input type="hidden" name="varify_file[Personal_References_Address]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Personal References Telephone</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Personal_References_Telephone; ?>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Personal_References_Telephone]" value="Personal References Telephone">
|
||
<textarea name="varify_data[Personal_References_Telephone]" style="display: none;"><?php echo $nurse->Personal_References_Telephone; ?></textarea>
|
||
<input type="hidden" name="varify_file[Personal_References_Telephone]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Profesonal References Name</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Profesonal_References_Name; ?>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Profesonal_References_Name]" value="Profesonal References Name">
|
||
<textarea name="varify_data[Profesonal_References_Name]" style="display: none;"><?php echo $nurse->Profesonal_References_Name; ?></textarea>
|
||
<input type="hidden" name="varify_file[Profesonal_References_Name]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Profesonal References Address</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Profesonal_References_Address; ?>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Profesonal_References_Address]" value="Profesonal References Address">
|
||
<textarea name="varify_data[Profesonal_References_Address]" style="display: none;"><?php echo $nurse->Profesonal_References_Address; ?></textarea>
|
||
<input type="hidden" name="varify_file[Profesonal_References_Address]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Profesonal References Telephone</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Profesonal_References_Telephone; ?>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Profesonal_References_Telephone]" value="Profesonal References Telephone">
|
||
<textarea name="varify_data[Profesonal_References_Telephone]" style="display: none;"><?php echo $nurse->Profesonal_References_Telephone; ?></textarea>
|
||
<input type="hidden" name="varify_file[Profesonal_References_Telephone]" value="">
|
||
</td>
|
||
</tr>
|
||
|
||
<!-- <tr><td colspan="3" class="verification-tab">Malpractice Insurance Policy</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Carrier Name</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Carrier_Name; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Carrier_Name]" value="Carrier Name">
|
||
<textarea name="varify_data[Carrier_Name]" style="display: none;"><?php echo $nurse->Carrier_Name; ?></textarea>
|
||
<input type="hidden" name="varify_file[Carrier_Name]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Policy Number</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Policy_Number; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Policy_Number]" value="Policy Number">
|
||
<textarea name="varify_data[Policy_Number]" style="display: none;"><?php echo $nurse->Policy_Number; ?></textarea>
|
||
<input type="hidden" name="varify_file[Policy_Number]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Expiration Date</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Expiration_Date; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Expiration_Date]" value="Expiration Date">
|
||
<textarea name="varify_data[Expiration_Date]" style="display: none;"><?php echo $nurse->Expiration_Date; ?></textarea>
|
||
<input type="hidden" name="varify_file[Expiration_Date]" value="">
|
||
</td>
|
||
</tr>
|
||
|
||
<tr><td colspan="3" class="verification-tab">Automobile Insurance Policy</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Automobile Policy Holder Name</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Automobile_Policy_Holder_Name; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Automobile_Policy_Holder_Name]" value="Automobile Policy Holder Name">
|
||
<textarea name="varify_data[Automobile_Policy_Holder_Name]" style="display: none;"><?php echo $nurse->Automobile_Policy_Holder_Name; ?></textarea>
|
||
<input type="hidden" name="varify_file[Automobile_Policy_Holder_Name]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Automobile Policy Number</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Automobile_Policy_Number; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Automobile_Policy_Number]" value="Automobile Policy Number">
|
||
<textarea name="varify_data[Automobile_Policy_Number]" style="display: none;"><?php echo $nurse->Automobile_Policy_Number; ?></textarea>
|
||
<input type="hidden" name="varify_file[Automobile_Policy_Number]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Automobile Policy Expiration Date</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Automobile_Policy_Expiration_Date; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Automobile_Policy_Expiration_Date]" value="Automobile Policy Expiration Date">
|
||
<textarea name="varify_data[Automobile_Policy_Expiration_Date]" style="display: none;"><?php echo $nurse->Automobile_Policy_Expiration_Date; ?></textarea>
|
||
<input type="hidden" name="varify_file[Automobile_Policy_Expiration_Date]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">CPR Certification (Expiration Date)</td>
|
||
<td class="verification-label-value"><?php echo $nurse->CPR_Certification_Expiration_Date; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[CPR_Certification_Expiration_Date]" value="CPR Certification (Expiration Date)">
|
||
<textarea name="varify_data[CPR_Certification_Expiration_Date]" style="display: none;"><?php echo $nurse->CPR_Certification_Expiration_Date; ?></textarea>
|
||
<input type="hidden" name="varify_file[CPR_Certification_Expiration_Date]" value="">
|
||
</td>
|
||
</tr> -->
|
||
|
||
<tr><td colspan="3" class="verification-tab">Additional Certifications</td></tr>
|
||
<?php for($i=0;$i<$additional_certificate_count;$i++){ ?>
|
||
<tr>
|
||
<td class="verification-label">Additional Certificate Details</td>
|
||
<td class="verification-label-value"><?php echo $documentsrem[_ADDL_CERTIFICATE_][$i]; ?>
|
||
<a class="" target="_blank" href="<?php echo $documentsarr[_ADDL_CERTIFICATE_][$i]; ?>">View</a>
|
||
</td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Additional_Certificate_Details<?php echo $i;?>]" value="Additional Certificate Details<?php echo $i;?>">
|
||
<textarea name="varify_data[Additional_Certificate_Details<?php echo $i;?>]" style="display: none;"><?php echo $documentsrem[_ADDL_CERTIFICATE_][$i]; ?></textarea>
|
||
<input type="hidden" name="varify_file[Additional_Certificate_Details<?php echo $i;?>]" value="<?php echo $documentsarr[_ADDL_CERTIFICATE_][$i]; ?>">
|
||
</td>
|
||
</tr>
|
||
<?php } ?>
|
||
<tr><td colspan="3" class="verification-tab">Emergency Contact</td></tr>
|
||
<tr>
|
||
<td class="verification-label">Name</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Name; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Emergency_Contact_Name]" value="Emergency Contact Name">
|
||
<textarea name="varify_data[Emergency_Contact_Name]" style="display: none;"><?php echo $nurse->Emergency_Contact_Name; ?></textarea>
|
||
<input type="hidden" name="varify_file[Emergency_Contact_Name]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Relationship</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Relationship; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Emergency_Contact_Relationship]" value="Emergency Contact Relationship">
|
||
<textarea name="varify_data[Emergency_Contact_Relationship]" style="display: none;"><?php echo $nurse->Emergency_Contact_Relationship; ?></textarea>
|
||
<input type="hidden" name="varify_file[Emergency_Contact_Relationship]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Address</td>
|
||
<td class="verification-label-value"><?php
|
||
$x = json_decode($nurse->Emergency_Contact_Address);
|
||
echo $x->Emergency_Contact_Address.','. $x->Emergency_Contact_zipcode;
|
||
?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Emergency_Contact_Address]" value="Emergency Contact Address">
|
||
<textarea name="varify_data[Emergency_Contact_Address]" style="display: none;"><?php echo $nurse->Emergency_Contact_Address; ?></textarea>
|
||
<input type="hidden" name="varify_file[Emergency_Contact_Address]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Telephone</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Telephone; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Emergency_Contact_Telephone]" value="Emergency Contact Telephone">
|
||
<textarea name="varify_data[Emergency_Contact_Telephone]" style="display: none;"><?php echo $nurse->Emergency_Contact_Telephone; ?></textarea>
|
||
<input type="hidden" name="varify_file[Emergency_Contact_Telephone]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Cellphone</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Cellphone; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Emergency_Contact_Cellphone]" value="Emergency Contact Cellphone">
|
||
<textarea name="varify_data[Emergency_Contact_Cellphone]" style="display: none;"><?php echo $nurse->Emergency_Contact_Cellphone; ?></textarea>
|
||
<input type="hidden" name="varify_file[Emergency_Contact_Cellphone]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Other</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Other; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Emergency_Contact_Other]" value="Emergency Contact Other">
|
||
<textarea name="varify_data[Emergency_Contact_Other]" style="display: none;"><?php echo $nurse->Emergency_Contact_Other; ?></textarea>
|
||
<input type="hidden" name="varify_file[Emergency_Contact_Other]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Email</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Email; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Emergency_Contact_Email]" value="Emergency Contact Email">
|
||
<textarea name="varify_data[Emergency_Contact_Email]" style="display: none;"><?php echo $nurse->Emergency_Contact_Email; ?></textarea>
|
||
<input type="hidden" name="varify_file[Emergency_Contact_Email]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Lives with patient</td>
|
||
<td class="verification-label-value"><?php echo $nurse->live_with_patient; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[live_with_patient]" value="Lives with patient">
|
||
<textarea name="varify_data[live_with_patient]" style="display: none;"><?php echo $nurse->live_with_patient; ?></textarea>
|
||
<input type="hidden" name="varify_file[live_with_patient]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Have Keys or access to home</td>
|
||
<td class="verification-label-value"><?php echo $nurse->have_key; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[have_key]" value="Have Keys or access to home">
|
||
<textarea name="varify_data[have_key]" style="display: none;"><?php echo $nurse->have_key; ?></textarea>
|
||
<input type="hidden" name="varify_file[have_key]" value="">
|
||
</td>
|
||
</tr>
|
||
|
||
<tr><td colspan="3" class="verification-tab">Caregiver Preference</td></tr>
|
||
<!-- <tr>
|
||
<td class="verification-label">Religious Preferences</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Religious_Preferences; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Religious_Preferences]" value="Religious Preferences">
|
||
<textarea name="varify_data[Religious_Preferences]" style="display: none;"><?php echo $nurse->Religious_Preferences; ?></textarea>
|
||
<input type="hidden" name="varify_file[Religious_Preferences]" value="">
|
||
</td>
|
||
</tr> -->
|
||
<tr>
|
||
<td class="verification-label">Preffered Gender</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Preffered_Gender; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Preffered_Gender]" value="Religious Gender">
|
||
<textarea name="varify_data[Preffered_Gender]" style="display: none;"><?php echo $nurse->Preffered_Gender; ?></textarea>
|
||
<input type="hidden" name="varify_file[Preffered_Gender]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Notes</td>
|
||
<td class="verification-label-value"><?php echo $nurse->Notes; ?></td>
|
||
<td class="verification-checked">
|
||
<input type="checkbox" name="varify_field[Notes]" value="Notes">
|
||
<textarea name="varify_data[Notes]" style="display: none;"><?php echo $nurse->Notes; ?></textarea>
|
||
<input type="hidden" name="varify_file[Notes]" value="">
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td class="verification-label">Accept</td>
|
||
<td class="verification-label-value"></td>
|
||
<td class="verification-checked">
|
||
<input type="radio" id="acceptYes" name="acceptCaregiver" value="YES" checked>
|
||
<label for="acceptYes">YES</label>
|
||
<input type="radio" id="acceptNo" name="acceptCaregiver" value="NO">
|
||
<label for="acceptNo">NO</label>
|
||
</td>
|
||
</tr>
|
||
<tr id="rejectionNote" style="display:none;" >
|
||
<td class="verification-label">Rejection Note</td>
|
||
<td class="verification-checked" colspan="2" width="100%">
|
||
<textarea name="rejectionNote"></textarea>
|
||
</td>
|
||
</tr>
|
||
|
||
</tbody>
|
||
</table>
|
||
</div>
|
||
<div class="col-md-12 text-center">
|
||
|
||
|
||
<button type="submit" id="submit_btn" name="submit" style="display:none" class="btn btn-info"><?php echo lang('submit'); ?></button>
|
||
<!-- <button id="checkAll" type="button" class="btn btn-info"><?php echo lang('check all'); ?></button> -->
|
||
</div>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</section>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
<script>
|
||
$("input[type='checkbox']").change(function(){
|
||
// alert("hii");
|
||
var a = $("input[type='checkbox']");
|
||
// if((a.length - 2)== a.filter(":checked").length){
|
||
if((a.length)== a.filter(":checked").length){
|
||
//alert('all checked');
|
||
$('#submit_btn').show();
|
||
}else{
|
||
$('#submit_btn').hide();
|
||
}
|
||
});
|
||
</script>
|
||
<script>
|
||
$("#checkAll").click(function(){
|
||
if (! $('input:checkbox').is('checked')) {
|
||
$('input:checkbox').attr('checked','checked');
|
||
} else {
|
||
$('input:checkbox').removeAttr('checked');
|
||
}
|
||
});
|
||
</script>
|
||
<script type="text/javascript">
|
||
/* future date dob not accept */
|
||
$(document).ready(function() {
|
||
// alert("dateSec");
|
||
var todaysDate = new Date(); // Gets today's date
|
||
|
||
// Max date attribute is in "YYYY-MM-DD". Need to format today's date accordingly
|
||
|
||
var year = todaysDate.getFullYear(); // YYYY
|
||
var month = ("0" + (todaysDate.getMonth() + 1)).slice(-2); // MM
|
||
var day = ("0" + todaysDate.getDate()).slice(-2); // DD
|
||
|
||
var maxDate = (year + "-" + month + "-" + day); // Results in "YYYY-MM-DD" for today's date
|
||
|
||
// Now to set the max date value for the calendar to be today's date
|
||
$('.ftrDate').attr('max', maxDate);
|
||
});
|
||
function validateAcceptance(){
|
||
|
||
var acceptCaregiver=$('input[name=acceptCaregiver]:checked').val();
|
||
//alert(acceptCaregiver);
|
||
var rejectionNote=$("textarea[name=rejectionNote]").val();
|
||
//alert(rejectionNote);
|
||
if(acceptCaregiver == 'YES')
|
||
{
|
||
return true;
|
||
// if (! $('input:checkbox').is('checked')) {
|
||
// return false;
|
||
// } else {
|
||
// return true;
|
||
// }
|
||
}
|
||
else
|
||
{
|
||
if(rejectionNote!='')
|
||
{
|
||
return true;
|
||
}
|
||
else
|
||
{
|
||
return false;
|
||
}
|
||
}
|
||
|
||
}
|
||
$('input[name=acceptCaregiver]').click(function(){
|
||
var acceptCaregiver=$(this).val();
|
||
//alert(acceptCaregiver);
|
||
if(acceptCaregiver=='NO'){
|
||
$("#rejectionNote").show();
|
||
}else{
|
||
$("#rejectionNote").hide();
|
||
}
|
||
});
|
||
</script>
|
||
<!--main content end-->
|
||
<!--footer start-->
|