273 lines
18 KiB
PHP
Executable File
273 lines
18 KiB
PHP
Executable File
<div use="otherReferenceFormContainer" style="display: none;">
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<div class="row" use="otherPart">
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<div class="form-group col-md-3">
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<label class="required-field"><?php echo lang('Other References Name'); ?></label>
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<input type="hidden" class="form-control referId" mname="referId" name="referId" class="form-control" id="referId">
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<input type="text" class="form-control" name="other_References_Name[]" mname="other_References_Name" required data-error="Please fill up the field.">
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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 class="required-field"><?php echo lang('Other References Address'); ?></label>
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<input type="text" class="form-control" name="other_References_Address[]" mname="other_References_Address" required data-error="Please fill up the field.">
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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 class="required-field"><?php echo lang('Other References Telephone'); ?></label>
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<input type="text" class="form-control" name="other_References_Telephone[]" mname="other_References_Telephone" required onkeypress="return isNumberKey(event)" onkeyup="USformatPhoneNumber(this.value,this)" onblur="USformatPhoneNumber(this.value,this)"
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data-error="Please fill up the field.">
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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-1 pd-25 plus_sec">
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<!-- <img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="less_education_documents(this,'<?php echo $documentsid[_DOC_TRAININGCODE_][0]; ?>');" class="img-thumbnail" style="height: 60px; cursor: pointer;"> -->
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<i class="la la-minus-circle" aria-hidden="true" use="minusbutt" onclick="less_other_reference(this);"></i>
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<!-- <img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="add_education_documents(null);" class="img-thumbnail" style="height: 50px; cursor: pointer;"> -->
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<!-- <i class="la la-plus-circle" aria-hidden="true" use="plusbutts" onclick="add_other_reference(null);"></i> -->
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</div>
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</div>
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</div>
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<div use="licenseUploadFormContainer" style="display: none;">
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<div class="row" use="licensePart">
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<input type="hidden" class="form-control licenseid" id="licenseid" name="licenseid" mname="licenseid">
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<div class="form-group col-md-4">
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<label class="required-field"><?php echo lang('License #'); ?></label>
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<input type="text" class="form-control" name="license_no[]" mname="license_no" required>
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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 class="required-field"><?php echo lang('State'); ?></label>
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<select class="form-control" name="rn_lic_state[]" mname="rn_lic_state" required data-error="Please fill up the field.">
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<option value="" disable selected>Select</option>
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<?php foreach ($state_list as $state) { ?>
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<option value="<?php echo $state->id; ?>" > <?php echo $state->name; ?>
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</option>
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<?php } ?>
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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-3">
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<label class="required-field"><?php echo lang('Expiration Date'); ?></label>
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<input type="date" class="form-control not-past-time" name="license_exp_date[]" mname="license_exp_date" required>
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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-1 pd-25 plus_sec">
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<!-- <img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="less_education_documents(this,'<?php echo $documentsid[_DOC_TRAININGCODE_][0]; ?>');" class="img-thumbnail" style="height: 60px; cursor: pointer;"> -->
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<i class="la la-minus-circle" aria-hidden="true" use="minusbutt" onclick="less_license_documents(this);"></i>
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<!-- <img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="add_education_documents(null);" class="img-thumbnail" style="height: 50px; cursor: pointer;"> -->
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<i class="la la-plus-circle" aria-hidden="true" use="plusbutt" onclick="add_license_documents(null);"></i>
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</div>
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</div>
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</div>
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<div use="educationUploadFormContainer" style="display: none;">
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<div class="row" use="educationPart">
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<div class="form-group col-md-4">
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<label class="required-field"><?php echo lang('School Name'); ?></label>
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<select class="form-control" name="school[]" mname="school" required>
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<?php foreach ($school_list as $school ) { ?>
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<option value="<?php echo $school->name; ?>"><?php echo $school->name; ?></option>
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<?php } ?>
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</select>
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</div>
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<div class="form-group col-md-2">
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<label class="required-field"><?php echo lang('Location of school'); ?></label>
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<input type="text" class="form-control" name="location_school[]" mname="location_school" required>
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</div>
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<!-- <div class="form-group col-md-1">
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<label class="required-field"><?php echo lang('Years'); ?></label>
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<select class="form-control" name="edu_years[]" mname="edu_years" required>
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<?php
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$now_year=date('Y');
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for($i=2001;$i<=$now_year;$i++){
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?>
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<option value="<?php echo $i;?>"><?php echo $i;?></option>
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<?php } ?>
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</select>
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<input type="text" class="form-control onlyNumber" minlength="4" maxlength="4" onkeypress="return isNumberKey(event)" onkeyup ="isFutureDate(this.value)" name="edu_years[]" mname="edu_years" required>
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<div class="yearError"></div>
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</div> -->
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<div class="form-group col-md-2">
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<label class="required-field"><?php echo lang('Degree/Certificate'); ?></label>
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<!-- <input type="text" class="form-control" name="major_subject[]" mname="major_subject" required> -->
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<select class="form-control" name="major_subject[]" mname="major_subject" required>
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<option value="">Select</option>
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<option value="Professional Certificate">Professional Certificate</option>
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<option value="HS Degree or Equivalent">HS Degree or Equivalent</option>
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<option value="Associate Degree">Associate Degree</option>
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<option value="Bachelor Degree">Bachelor Degree</option>
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<option value="Graduate Degree">Graduate Degree</option>
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<option value="Master Degree">Master Degree</option>
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<option value="Doctoral Degree">Doctoral Degree</option>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label class="required-field"><?php echo lang('Graduation Date'); ?></label>
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<input type="month" class="form-control not-future-month" name="certificate_date[]" mname="certificate_date" onkeyup ="isFutureDate(this.value)" required>
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</div>
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<div class="form-group col-md-1 pd-25 plus_sec">
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<!-- <img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="less_education_documents(this,'<?php echo $documentsid[_DOC_TRAININGCODE_][0]; ?>');" class="img-thumbnail" style="height: 60px; cursor: pointer;"> -->
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<i class="la la-minus-circle" aria-hidden="true" use="minusbutt" onclick="less_education_documents(this,'<?php echo $documentsid[_DOC_TRAININGCODE_][0]; ?>');"></i>
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<!-- <img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="add_education_documents(null);" class="img-thumbnail" style="height: 50px; cursor: pointer;"> -->
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<i class="la la-plus-circle" aria-hidden="true" use="plusbutt" onclick="add_education_documents(null);"></i>
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</div>
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</div>
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</div>
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<div use="trainingUploadFormContainer" style="display: none;">
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<form action="<?php echo base_url(); ?>CaregiversDashboard/documentsSave" method="post" enctype="multipart/form-data" use="trainingUploadForm">
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<input type="hidden" id="csrf" value="<?php echo $this->security->get_csrf_hash();?>" name="<?php echo $this->security->get_csrf_token_name();?>" >
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<div class="row">
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<input type="hidden" name="Ion_id" id="caregiver_ion_id" value="<?php if (!empty($nurse->ion_user_id)) echo $nurse->ion_user_id; ?>">
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<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
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<input type="hidden" name="doc_type" value="<?php echo _DOC_TRAININGCODE_ ; ?>">
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<input type="hidden" name="doc_id" value="">
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<input type="hidden" name="progress" value="10">
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<div class="form-group col-md-5">
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<label class="required-field"><?php echo lang('Aditional Certificates (gif/jpg/png/jpeg/pdf)'); ?></label>
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<input type="file" class="form-control" name="TRN" required>
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</div>
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<div class="form-group col-md-2">
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<label class="required-field"><?php echo lang('Name Additional Certifications'); ?></label>
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<input type="text" class="form-control" name="TRN_remarks" required>
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</div>
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<div class="form-group col-md-2">
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<label class="required-field"><?php echo lang('Additional Certifications Number'); ?></label>
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<input type="text" class="form-control" name="TRN_documents_no" required>
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</div>
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<div class="form-group col-md-1">
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<button class="btn btn-primary file-upload" name="upload" type="submit"> Upload</button>
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</div>
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<div class="form-group col-md-1">
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<span use="uploadContainer"></span>
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</div>
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<div class="form-group col-md-1">
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<img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="less_training_documents(this,'<?php echo $documentsid[_DOC_TRAININGCODE_][0]; ?>');" class="img-thumbnail" style="height: 60px; cursor: pointer;">
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<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="add_training_documents(null);" class="img-thumbnail" style="height: 50px; cursor: pointer;">
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</div>
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</div>
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</form>
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</div>
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<div use="otherUploadFormContainer" style="display: none;">
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<form action="<?php echo base_url(); ?>CaregiversDashboard/documentsSave" method="post" enctype="multipart/form-data" use="otherUploadForm">
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<input type="hidden" id="csrf" value="<?php echo $this->security->get_csrf_hash();?>" name="<?php echo $this->security->get_csrf_token_name();?>" >
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<div class="row">
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<input type="hidden" name="Ion_id" id="caregiver_ion_id" value="<?php if (!empty($nurse->ion_user_id)) echo $nurse->ion_user_id; ?>">
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<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
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<input type="hidden" name="doc_type" value="<?php echo _DOC_OTHERCODE_ ; ?>">
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<input type="hidden" name="doc_id" value="">
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<input type="hidden" name="progress" value="10">
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<div class="form-group col-md-4">
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<label><?php echo lang('Other Documents'); ?></label>
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<input type="file" class="form-control" name="<?php echo _DOC_OTHERCODE_ ; ?>" required>
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</div>
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<div class="form-group col-md-5">
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<label ><?php echo lang('Documents Name'); ?></label>
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<input type="text" class="form-control" id="<?php echo _DOC_OTHERCODE_ ; ?>_remarks" name="<?php echo _DOC_OTHERCODE_ ; ?>_remarks" required>
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</div>
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<div class="form-group col-md-1 mt-2 row">
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<div class="cameraIcon">
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<a data-toggle="modal" class="mm" type="vaccine" myidValue="<?php echo $documentsid[_DOC_OTHERCODE_][0]; ?>" myValue="<?php echo _DOC_OTHERCODE_; ?>" data-dismiss="modal" aria-hidden="true" >
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<i class="fa fa-camera" style="font-size:24px" onclick="openCameraForDate(this)"></i>
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</a>
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</div>
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<button class="btn btn-primary file-upload" name="upload" type="submit"> Upload</button>
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</div>
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<div class="form-group col-md-1">
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<span use="uploadContainer"></span>
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</div>
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<div class="form-group col-md-1 pd-25 plus_sec">
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<i class="la la-minus-circle" aria-hidden="true" use="minusbutt" onclick="less_other_documents(this,'<?php echo $documentsid[_DOC_OTHERCODE_][0]; ?>');"></i>
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<i class="la la-plus-circle" aria-hidden="true" use="plusbutt" onclick="add_other_documents(null);"></i>
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<!-- <img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="less_other_documents(this,'<?php echo $documentsid[_DOC_OTHERCODE_][0]; ?>');" class="img-thumbnail" style="height: 60px; cursor: pointer;">
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<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="add_other_documents(null);" class="img-thumbnail" style="height: 50px; cursor: pointer;"> -->
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</div>
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</div>
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</form>
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</div>
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<div use="moreAdditionalCertificateFormContainer" style="display:none;">
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<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/profileOtherInfo" method="post" enctype="multipart/form-data" use="docUploadForm">
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<!-- <?php echo $csrfHash = $this->security->get_csrf_hash();?> -->
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<input type="hidden" id="csrf" value="<?php echo $this->security->get_csrf_hash();?>" name="<?php echo $this->security->get_csrf_token_name();?>" >
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<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
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<input type="hidden" name="Ion_id" id="caregiver_ion_id" value="<?php if (!empty($nurse->ion_user_id)) echo $nurse->ion_user_id; ?>" >
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<input type="hidden" name="form_status" value="5">
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<input type="hidden" name="progress" value="0">
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<input type="hidden" name="data_type" value="Additional_Certifications">
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<input type="hidden" name="form_mode" value="Add">
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<input type="hidden" name="doc_type" value="<?php echo _ADDL_CERTIFICATE_ ; ?>">
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<input type="hidden" name="doc_id" value="">
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<div class="row">
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<div class="form-group col-md-3">
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<label ><?php echo lang('State'); ?></label>
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<select class="form-control" name="Name_Additional_Certifications_state" required>
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<?php
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foreach ($state_list as $value) {
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?>
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<option value="<?php echo $value->id; ?>"><?php echo $value->name ?></option>
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<?php
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label ><?php echo lang('Licenses or Certification'); ?></label>
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<select class="form-control" name="Name_Additional_Certifications" required>
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<option value="RN Licenses">RN Licenses</option>
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<option value="LPN Licenses">LPN Licenses</option>
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<option value="IV Certification">IV Certification</option>
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<option value="HHA/PCA Certificate">HHA/PCA Certificate</option>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label ><?php echo lang('Licenses or Certification Number'); ?></label>
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<input type="text" class="form-control" name="Additional_Certifications_Number" required>
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</div>
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<div class="form-group col-md-3 ">
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<label ><?php echo lang('Certifications Document'); ?></label>
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<input type="file" class="form-control" name="<?php echo _ADDL_CERTIFICATE_ ; ?>" required>
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</div>
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<div class="col-md-1 mt-2">
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<button type="submit" name="submit" class="btn btn-info "><?php echo lang('Update'); ?></button>
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</div>
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<div class="form-group col-md-1">
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<span use="uploadContainer"></span>
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</div>
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<div class="form-group col-md-1 pd-25 plus_sec">
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<i class="la la-minus-circle" aria-hidden="true" use="minusbutt" onclick="less_additional_certificates(this,'<?php echo $documentsid[_ADDL_CERTIFICATE_][0]; ?>');"></i>
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<i class="la la-plus-circle" aria-hidden="true" use="plusbutt" onclick="add_additional_certificates(null);"></i>
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<!-- <img src="<?php echo base_url(); ?>uploads/minus.png" use="minusbutt" onclick="less_additional_certificates(this,'<?php echo $documentsid[_ADDL_CERTIFICATE_][0]; ?>');" class="img-thumbnail" style="height: 60px; cursor: pointer;">
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<img src="<?php echo base_url(); ?>uploads/plus.png" use="plusbutt" onclick="add_additional_certificates(null);" class="img-thumbnail" style="height: 50px; cursor: pointer;"> -->
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</div>
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</div>
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</form>
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</div>
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<div class="modal fade" id="NPI_Check_Modal" tabindex="-1" role="dialog" aria-labelledby="exampleModalCenterTitle" aria-hidden="true">
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<div class="modal-dialog modal-lg modal-dialog-centered" role="document" style="max-width: 95%;!important">
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<div class="modal-content">
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<div class="modal-header">
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<h3 class="modal-title" id="exampleModalLongTitle">Check NPI Info</h3>
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<button type="button" class="close" data-dismiss="modal" aria-label="Close">
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<span aria-hidden="true">×</span>
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</button>
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</div>
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<div class="modal-body full-height-view">
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<iframe src="https://npiregistry.cms.hhs.gov/" width="100%" height="100%" style="height:70vh;"></iframe>
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</div>
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<div class="modal-footer">
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<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
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</div>
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</div>
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</div>
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</div>
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