2339 lines
125 KiB
PHP
Executable File
2339 lines
125 KiB
PHP
Executable File
<link href="https://www.jqueryscript.net/css/jquerysctipttop.css" rel="stylesheet" type="text/css">
|
||
<link rel="stylesheet" href="<?php echo base_url(); ?>common/signature/drawing-table.css" type="text/css" media="screen" charset="utf-8" />
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<script type="text/javascript" src="https://pagead2.googlesyndication.com/pagead/show_ads.js"></script>
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<link href="https://cdnjs.cloudflare.com/ajax/libs/select2/4.0.6-rc.0/css/select2.min.css" rel="stylesheet" />
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<script src="https://cdnjs.cloudflare.com/ajax/libs/select2/4.0.6-rc.0/js/select2.min.js"></script>
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<script src="https://cdn.jsdelivr.net/npm/sweetalert2@9"></script>
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<style type="text/css">
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div.patient-view-card-container{margin-top:5px;}
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.patient-view-card-icons{font-size:40px;}
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.patient-view-card{transition: 0.4s;padding: 10px 0;border:1px solid rgba(0,0,0,0.1);}
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.patient-view-card:hover{box-shadow:5px 10px 10px rgba(0, 0, 0, 0.1);transition:0.4s;}
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.fa-pencil{cursor:pointer;color:#fff;}
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</style>
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<style type="text/css">
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span.highlight-container{width: 100px;}
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i.highlight{position: relative;animation-name: example;animation-duration: 2.5s;animation-iteration-count: 3;}
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@keyframes example {
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0% {left:0px;}
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100% {left:90px;}
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}
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@media(max-width: 500px){
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span.highlight-container{display: none;}
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}
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canvas.form-control {
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height: 200px;
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}
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</style>
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<!-- tabs section -->
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<ul class="nav nav-tabs nav-linetriangle no-hover-bg disclosure-pdf-tabs" id="myTab" role="tablist" style="border: none; margin-bottom: 20px;">
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<?php
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$active='active';
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foreach ($disclosures as $disclosure) {
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if($disclosure['short_code']=='ContractorAgreement'){$disclosure['id']='con-agree-tab'; }
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if($disclosure['short_code']=='DirectDiposit'){$disclosure['id']='dir-depo-tab'; }
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if($disclosure['short_code']=='iNineForm'){$disclosure['id']='i-nine-tab'; }
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if($disclosure['short_code']=='wNineForm'){$disclosure['id']='w-nine-tab'; }
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?>
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<li class="nav-item disclouser_tab <?=$active?>" >
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<a class="nav-link doc_tab_top" id="<?=$disclosure['id']?>" data-toggle="tab" href="#<?=$disclosure['id']?>-dsc" role="tab" aria-selected="false" style="cursor: pointer;">
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<?=$disclosure['name']?>
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</a>
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</li>
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<?php
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$active='';
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}
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?>
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<li class="nav-item disclouser_tab" >
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<!-- <a class="nav-link doc_tab_top" id="" data-toggle="tab" href="#-dsc" role="tab" aria-selected="false" style="cursor: pointer;"> -->
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<a class="nav-link doc_tab_top" id="" href="http://localhost/dev.wecuro.com/onboarding/process/55a7cf9c71f1c9c495413f934dd1a158" style="cursor: pointer;">
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Back to Onboarding
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</a>
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</li>
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</ul>
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<!-- Ending of tabs section -->
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<!-- Disclosure tabs content section -->
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<div class="tab-content disclosure-pdf-container" id="myTabContent">
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<input type="hidden" id="cg_id" value="<?php echo $user->id;?>">
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<input type="hidden" id="cgType" value="<?php echo $user->qualification_type;?>">
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<div class="tab-pane disc_tab fade active in" id="con-agree-tab-dsc" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
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<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('con_agree_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
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<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
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<input type="hidden" name="documentType" value="ContractorAgreement">
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<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
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<!-- for refrashing the pdf page -->
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<input type="hidden" id="tab_specific_id" value="con-agree-tab">
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<!-- for refrashing the pdf page -->
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<!-- calling the modal for inserting extra outer info -->
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<?php
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/*
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if(!in_array("ContractorAgreement",$signature_type)){
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?>
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<div class="row mb-2 extra-info-pdf-con-agree-tab">
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<div class="col-lg-12 form-group">
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<span class="float-right mx-2">
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<button class="btn btn-info" type="button" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#infoModal" data-whatever="@mdo">
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<i class="fa fa-pencil" ></i>
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<?php echo lang('Click Here To Fill More Info'); ?>
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</button>
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</span>
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<span class="float-right highlight-container">
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<i class="fa fa-2x fa-hand-o-right text-info highlight"></i>
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</span>
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</div>
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</div>
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<?php
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}*/
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?>
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<!-- calling the modal for inserting extra outer info -->
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<!-- Contractor Agreement pdf -->
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<div class="row pdf-form-container-con-agree-tab">
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<?php $url=$user_folder."/"."CONTRACTOR_AGREEMENT_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
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<div class="col-lg-12 form-group pdf-form-con-agree-tab">
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<?php
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// if(!in_array("ContractorAgreement",$signature_type)){
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// $url=$endAppPath."contractor_agreement.pdf";
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// }else{
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// $url=$user_folder."/"."CONTRACTOR_AGREEMENT_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf";
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// }
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?>
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<embed
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src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
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type="application/pdf"
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frameBorder="0"
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scrolling="auto"
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height="600px"
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width="100%"
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></embed>
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</div>
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<div class="col-lg-12 form-group">
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<input type="hidden" name="signature" id="signature_final_field_con_agree_tab" value="">
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<input type="hidden" name="date" id="signature_final_date_con_agree_tab" value="">
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</div>
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</div>
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<!-- End of Contractor Agreement pdf -->
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<hr class="mt-3">
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<?php
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// if(!in_array("ContractorAgreement",$signature_type))
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if(!in_array("ContractorAgreement",$signature_type))
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{
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?>
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<div id="date_signature_container_con_agree_tab">
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<div class="row mt-3">
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<div class="col-lg-6 form-group">
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<label>Signature</label>
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<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('con_agree_tab')" class="badge badge-info">Erasess</span></label>
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<canvas class="form-control" id="signature_canvas_con_agree_tab" width="400" height="200" ></canvas>
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</div>
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<div class="col-lg-6 form-group">
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<label>Date</label>
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<?php $now_time=date('Y-m-d'); ?>
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<input type="datetime" class="form-control" name="signature_field_date_con_agree_tab" id="signature_field_date_con_agree_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
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</div>
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</div>
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<hr>
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<!-- <div class="row">
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<div class="col-lg-6 form-group">
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<input class="sigorwrite" type="checkbox" name="signature_type" id="con_agree_tab" value="write">
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<label><b>Or Type Your Name</b></label>
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<input type="text" class="form-control" id="signature_field_write_con_agree_tab" value="" disabled="">
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</div>
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<div class="col-lg-6 form-group">
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<label>Date</label>
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<?php $now_time=date('Y-m-d'); ?>
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<input type="datetime" class="form-control" id="signature_field_date_write_con_agree_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
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</div>
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</div> -->
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<div class="row">
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<div class="form-group col-md-12" style="padding: 20px;">
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<button type="submit" name="submit" class="btn btn-info next_con_agree_tab" onclick="return signatureVal('con_agree_tab')"><?php echo lang('Save'); ?></button>
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</div>
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</div>
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</div>
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<?php
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}else{
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?>
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<div class="row">
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<div class="form-group col-md-12" style="padding: 20px;">
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<button type="button" class="btn btn-info next_con_agree_tab"><?php echo lang('Next'); ?></button>
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</div>
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</div>
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<?php
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}
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?>
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<div class="container-next" id="container_next_con_agree_tab">
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<div class="row">
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<div class="form-group col-md-12" style="padding: 20px;">
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<button type="button" class="btn btn-info next_con_agree_tab"><?php echo lang('Next'); ?></button>
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</div>
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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="tab-pane disc_tab fade" id="bak-check-tab-dsc" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
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<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('bak_check_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
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<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
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<input type="hidden" name="documentType" value="BackgroundCheck">
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<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
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<!-- for refrashing the pdf page -->
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<input type="hidden" id="tab_specific_id" value="bak-check-tab">
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<!-- for refrashing the pdf page -->
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<!-- calling the modal for inserting extra outer info -->
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<?php
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if(!in_array("BackgroundCheck",$signature_type)){
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?>
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<div class="row mb-2 extra-info-pdf-bak-check-tab">
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<div class="col-lg-12 form-group">
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<span class="float-right mx-2">
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<button class="btn btn-info" type="button" id="card_2_edit" aria-hidden="true" data-toggle="modal" data-target="#infoModal" data-whatever="@mdo">
|
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<i class="fa fa-pencil" ></i>
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<?php echo lang('Click Here To Fill More Info'); ?>
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</button>
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</span>
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<span class="float-right highlight-container">
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<i class="fa fa-2x fa-hand-o-right text-info highlight"></i>
|
||
</span>
|
||
</div>
|
||
</div>
|
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<?php
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}
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?>
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<!-- calling the modal for inserting extra outer info -->
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||
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<!-- Background Check Form pdf -->
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<div class="row pdf-form-container-bak-check-tab">
|
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<?php $url=$user_folder."/"."BACKGROUND_CHECK_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
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<div class="col-lg-12 form-group pdf-form-bak-check-tab">
|
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<?php
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// if(!in_array("BackgroundCheck",$signature_type)){
|
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// $url=$endAppPath."background_check.pdf";
|
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// }else{
|
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// $url=$user_folder."/"."BACKGROUND_CHECK_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf";
|
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// }
|
||
?>
|
||
<embed
|
||
src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
|
||
type="application/pdf"
|
||
frameBorder="0"
|
||
scrolling="auto"
|
||
height="600px"
|
||
width="100%"
|
||
></embed>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<input type="hidden" name="signature" id="signature_final_field_bak_check_tab" value="">
|
||
<input type="hidden" name="date" id="signature_final_date_bak_check_tab" value="">
|
||
</div>
|
||
</div>
|
||
<!-- End of Background Check Form pdf -->
|
||
|
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<hr class="mt-3">
|
||
<?php
|
||
if(!in_array("BackgroundCheck",$signature_type))
|
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{
|
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?>
|
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<div id="date_signature_container_bak_check_tab">
|
||
<div class="row mt-3">
|
||
<div class="col-lg-6 form-group">
|
||
<label>Signature</label>
|
||
<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('bak_check_tab')" class="badge badge-info">Erasess</span></label>
|
||
<canvas class="form-control" id="signature_canvas_bak_check_tab" width="400" height="200" ></canvas>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" name="signature_field_date_bak_check_tab" id="signature_field_date_bak_check_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
<!-- <div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<input class="sigorwrite" type="checkbox" name="signature_type" id="bak_check_tab" value="write">
|
||
<label><b>Or Type Your Name</b></label>
|
||
<input type="text" class="form-control" id="signature_field_write_bak_check_tab" value="" disabled="">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" id="signature_field_date_write_bak_check_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
|
||
</div>
|
||
</div> -->
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="submit" name="submit" class="btn btn-info next_bak_check_tab" onclick="return signatureVal('bak_check_tab')"><?php echo lang('Save'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_bak_check_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}
|
||
?>
|
||
<div class="container-next" id="container_next_bak_check_tab">
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_bak_check_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
|
||
<div class="tab-pane disc_tab fade" id="i-nine-tab-dsc" 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(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('i_nine_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="documentType" value="iNineForm">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<!-- for refrashing the pdf page -->
|
||
<input type="hidden" id="tab_specific_id" value="i-nine-tab">
|
||
<!-- for refrashing the pdf page -->
|
||
|
||
<!-- calling the modal for inserting extra outer info -->
|
||
<?php
|
||
/*if(!in_array("iNineForm",$signature_type)){
|
||
?>
|
||
<div class="row mb-2 extra-info-pdf-i-nine-tab">
|
||
<div class="col-lg-12 form-group">
|
||
<span class="float-right mx-2">
|
||
<button class="btn btn-info" type="button" id="card_3_edit" aria-hidden="true" data-toggle="modal" data-target="#infoModal" data-whatever="@mdo">
|
||
<i class="fa fa-pencil" ></i>
|
||
<?php echo lang('Click Here To Fill More Info'); ?>
|
||
</button>
|
||
</span>
|
||
<span class="float-right highlight-container">
|
||
<i class="fa fa-2x fa-hand-o-right text-info highlight"></i>
|
||
</span>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}*/
|
||
?>
|
||
<!-- calling the modal for inserting extra outer info -->
|
||
|
||
<!-- i-9 Form pdf -->
|
||
<div class="row pdf-form-container-i-nine-tab">
|
||
<?php $url=$user_folder."/"."I_NINE_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
|
||
<div class="col-lg-12 form-group pdf-form-i-nine-tab">
|
||
<?php
|
||
// if(!in_array("iNineForm",$signature_type)){
|
||
// $url=$endAppPath."i_nine.pdf";
|
||
// }else{
|
||
// $url=$user_folder."/"."I_NINE_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf";
|
||
// }
|
||
?>
|
||
<embed
|
||
src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
|
||
type="application/pdf"
|
||
frameBorder="0"
|
||
scrolling="auto"
|
||
height="600px"
|
||
width="100%"
|
||
></embed>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<input type="hidden" name="signature" id="signature_final_field_i_nine_tab" value="">
|
||
<input type="hidden" name="date" id="signature_final_date_i_nine_tab" value="">
|
||
</div>
|
||
</div>
|
||
<!-- End of i-9 Form pdf -->
|
||
|
||
<hr class="mt-3">
|
||
<?php
|
||
if(!in_array("iNineForm",$signature_type))
|
||
{
|
||
?>
|
||
<div id="date_signature_container_i_nine_tab">
|
||
<div class="row mt-3">
|
||
<div class="col-lg-6 form-group">
|
||
<label>Signature</label>
|
||
<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('i_nine_tab')" class="badge badge-info">Erasess</span></label>
|
||
<canvas class="form-control" id="signature_canvas_i_nine_tab" width="400" height="200" ></canvas>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" name="signature_field_date_i_nine_tab" id="signature_field_date_i_nine_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
<!-- <div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<input class="sigorwrite" type="checkbox" name="signature_type" id="i_nine_tab" value="write">
|
||
<label><b>Or Type Your Name</b></label>
|
||
<input type="text" class="form-control" id="signature_field_write_i_nine_tab" value="" disabled="">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" id="signature_field_date_write_i_nine_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
|
||
</div>
|
||
</div> -->
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="submit" name="submit" class="btn btn-info next_i_nine_tab" onclick="return signatureVal('i_nine_tab')"><?php echo lang('Save'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_i_nine_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}
|
||
?>
|
||
<div class="container-next" id="container_next_i_nine_tab">
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_i_nine_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
|
||
<div class="tab-pane disc_tab fade" id="w-nine-tab-dsc" 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(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('w_nine_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="documentType" value="wNineForm">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<!-- for refrashing the pdf page -->
|
||
<input type="hidden" id="tab_specific_id" value="w-nine-tab">
|
||
<!-- for refrashing the pdf page -->
|
||
|
||
|
||
<!-- calling the modal for inserting extra outer info -->
|
||
<?php
|
||
/* if(!in_array("wNineForm",$signature_type)){
|
||
?>
|
||
<!-- <div class="row mb-2">
|
||
<div class="col-lg-12 form-group">
|
||
<span class="float-right mx-2">
|
||
<i class="fa fa-pencil" id="card_4_edit" aria-hidden="true" data-toggle="modal" data-target="#infoModal" data-whatever="@mdo"></i>
|
||
</span>
|
||
</div>
|
||
</div> -->
|
||
<div class="row mb-2 extra-info-pdf-w-nine-tab">
|
||
<div class="col-lg-12 form-group">
|
||
<span class="float-right mx-2">
|
||
<button class="btn btn-info" type="button" id="card_4_edit" aria-hidden="true" data-toggle="modal" data-target="#infoModal" data-whatever="@mdo">
|
||
<i class="fa fa-pencil" ></i>
|
||
<?php echo lang('Click Here To Fill More Info'); ?>
|
||
</button>
|
||
</span>
|
||
<span class="float-right highlight-container">
|
||
<i class="fa fa-2x fa-hand-o-right text-info highlight"></i>
|
||
</span>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}*/
|
||
?>
|
||
<!-- calling the modal for inserting extra outer info -->
|
||
|
||
|
||
<!-- w-9 Form pdf -->
|
||
<div class="row pdf-form-container-w-nine-tab">
|
||
<?php $url=$user_folder."/"."W_NINE_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
|
||
<div class="col-lg-12 form-group pdf-form-w-nine-tab">
|
||
<?php
|
||
// if(!in_array("wNineForm",$signature_type)){
|
||
// $url=$endAppPath."w_nine.pdf";
|
||
// }else{
|
||
// $url=$user_folder."/"."W_NINE_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf";
|
||
// }
|
||
?>
|
||
<embed
|
||
src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
|
||
type="application/pdf"
|
||
frameBorder="0"
|
||
scrolling="auto"
|
||
height="600px"
|
||
width="100%"
|
||
></embed>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<input type="hidden" name="signature" id="signature_final_field_w_nine_tab" value="">
|
||
<input type="hidden" name="date" id="signature_final_date_w_nine_tab" value="">
|
||
</div>
|
||
</div>
|
||
<!-- End of w-9 Form pdf -->
|
||
|
||
<hr class="mt-3">
|
||
<?php
|
||
if(!in_array("wNineForm",$signature_type))
|
||
{
|
||
?>
|
||
<div id="date_signature_container_w_nine_tab">
|
||
<div class="row mt-3">
|
||
<div class="col-lg-6 form-group">
|
||
<label>Signature</label>
|
||
<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('w_nine_tab')" class="badge badge-info">Erasess</span></label>
|
||
<canvas class="form-control" id="signature_canvas_w_nine_tab" width="400" height="200" ></canvas>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" name="signature_field_date_w_nine_tab" id="signature_field_date_w_nine_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
<!-- <div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<input class="sigorwrite" type="checkbox" name="signature_type" id="w_nine_tab" value="write">
|
||
<label><b>Or Type Your Name</b></label>
|
||
<input type="text" class="form-control" id="signature_field_write_w_nine_tab" value="" disabled="">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" id="signature_field_date_write_w_nine_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
|
||
</div>
|
||
</div> -->
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="submit" name="submit" class="btn btn-info next_w_nine_tab" onclick="return signatureVal('w_nine_tab')"><?php echo lang('Save'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_w_nine_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}
|
||
?>
|
||
<div class="container-next" id="container_next_w_nine_tab">
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_w_nine_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
|
||
<!-- 16-11-2021 -->
|
||
<div class="tab-pane disc_tab fade" id="dir-depo-tab-dsc" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
|
||
<!-- calling the modal for inserting extra outer info -->
|
||
<?php
|
||
/*if(!in_array("DirectDiposit",$signature_type)){
|
||
?>
|
||
<div class="row mb-2 extra-info-pdf-dir-depo-tab">
|
||
<div class="col-lg-12 form-group">
|
||
<span class="float-right mx-2">
|
||
<button class="btn btn-info" type="button" id="card_5_edit" aria-hidden="true" data-toggle="modal" data-target="#infoModal" data-whatever="@mdo">
|
||
<i class="fa fa-pencil" ></i>
|
||
<?php echo lang('Click Here To Fill More Info'); ?>
|
||
</button>
|
||
</span>
|
||
<span class="float-right highlight-container">
|
||
<i class="fa fa-2x fa-hand-o-right text-info highlight"></i>
|
||
</span>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}*/
|
||
?>
|
||
<!-- calling the modal for inserting extra outer info -->
|
||
|
||
|
||
<!-- Direct Deposit pdf -->
|
||
<div class="row pdf-form-container-dir-depo-tab">
|
||
<?php $url=$user_folder."/"."DIRECT_DEPOSIT_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
|
||
<div class="col-lg-12 form-group pdf-form-dir-depo-tab">
|
||
<?php
|
||
// if(!in_array("DirectDiposit",$signature_type)){
|
||
// $url=$endAppPath."direct_deposit.pdf";
|
||
// }else{
|
||
// $url=$user_folder."/"."DIRECT_DEPOSIT_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf";
|
||
// }
|
||
?>
|
||
<embed
|
||
src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
|
||
type="application/pdf"
|
||
frameBorder="0"
|
||
scrolling="auto"
|
||
height="600px"
|
||
width="100%"
|
||
></embed>
|
||
</div>
|
||
</div>
|
||
<!-- End of Direct Deposit pdf -->
|
||
|
||
<hr class="mt-3">
|
||
<?php
|
||
if(!in_array("DirectDiposit",$signature_type)){
|
||
?>
|
||
<div id="date_signature_container_dir_depo_tab">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('dir_depo_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="documentType" value="DirectDiposit">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<!-- for refrashing the pdf page -->
|
||
<input type="hidden" id="tab_specific_id" value="dir-depo-tab">
|
||
<!-- for refrashing the pdf page -->
|
||
|
||
<input type="hidden" name="signature" id="signature_final_field_dir_depo_tab" value="">
|
||
<input type="hidden" name="date" id="signature_final_date_dir_depo_tab" value="">
|
||
|
||
<div class="row mt-3">
|
||
<div class="col-lg-6 form-group">
|
||
<label>Signature</label>
|
||
<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('dir_depo_tab')" class="badge badge-info">Erasess</span></label>
|
||
<canvas class="form-control" id="signature_canvas_dir_depo_tab" width="400" height="200" ></canvas>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" name="signature_field_date_dir_depo_tab" id="signature_field_date_dir_depo_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
<!-- <div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<input class="sigorwrite" type="checkbox" name="signature_type" id="dir_depo_tab" value="write">
|
||
<label><b>Or Type Your Name</b></label>
|
||
<input type="text" class="form-control" id="signature_field_write_dir_depo_tab" value="" disabled="">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" id="signature_field_date_write_dir_depo_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
|
||
</div>
|
||
</div> -->
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="submit" name="submit" class="btn btn-info next_dir_depo_tab" onclick="return signatureVal('dir_depo_tab')"><?php echo lang('Save'); ?></button>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
/*
|
||
if($cg_type!="D"){
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/final_pdf" method="post" enctype="multipart/form-data" class="needs-validation">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash();?>" />
|
||
<input type="hidden" name="documentType" value="DirectDiposit">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<input type="hidden" name="cg_type" value="<?php echo $cg_type;?>" readonly>
|
||
|
||
<?php
|
||
//AB
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5" || $q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "contrator" ){
|
||
if($ab_type=="true"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank">
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}if($ab_type=="false"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank" disabled>
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
}
|
||
//C
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5") && $q_e_type->employee_type == "inhouse"){
|
||
if($c_type=="true"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank">
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}if($c_type=="false"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank" disabled>
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
}
|
||
?>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/send_approval" method="post" enctype="multipart/form-data" class="needs-validation" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="form_tab_status" value="12">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<input type="hidden" name="form_status" value="12">
|
||
<input type="hidden" name="ion_id" value="<?php echo $nurse->ion_user_id; ?>">
|
||
|
||
<div class="row">
|
||
<div class="form-group col-md-8" style="padding: 20px;">
|
||
<?php
|
||
if($sigTabStatus==1){
|
||
?>
|
||
<input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<span class="required-field text-info">
|
||
<?php echo lang("Please Sign to the all Signature Panels before Print or Submit for Approval");?>
|
||
</span>
|
||
<?php
|
||
}
|
||
?>
|
||
<!-- <input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label> -->
|
||
</div>
|
||
<div class="form-group col-md-4" style="padding: 20px;">
|
||
<?php
|
||
//AB
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5" || $q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "contrator" ){
|
||
if($ab_type=="true"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right">
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}if($ab_type=="false"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right" disabled>
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
}
|
||
//C
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5") && $q_e_type->employee_type == "inhouse"){
|
||
if($c_type=="true"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right">
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}if($c_type=="false"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right" disabled>
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
}
|
||
?>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
*/ ?>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_dir_depo_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
// }
|
||
}
|
||
?>
|
||
<div class="container-next" id="container_next_dir_depo_tab">
|
||
<?php
|
||
if($cg_type!="D"){
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/final_pdf" method="post" enctype="multipart/form-data" class="needs-validation">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash();?>" />
|
||
<input type="hidden" name="documentType" value="DirectDiposit">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<input type="hidden" name="cg_type" value="<?php echo $cg_type;?>" readonly>
|
||
|
||
<?php
|
||
//AB
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5" || $q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "contrator" ){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank" disabled>
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
//C
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5") && $q_e_type->employee_type == "inhouse"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank" disabled>
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
?>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/send_approval" method="post" enctype="multipart/form-data" class="needs-validation" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="form_tab_status" value="12">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<input type="hidden" name="form_status" value="12">
|
||
|
||
<div class="row">
|
||
<div class="form-group col-md-8" style="padding: 20px;">
|
||
<?php
|
||
if($sigTabStatus==1){
|
||
?>
|
||
<input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<span class="required-field text-info">
|
||
<?php echo lang("Please Sign to the all Signature Panels before Print or Submit for Approval");?>
|
||
</span>
|
||
<br>
|
||
<span class="text-info">
|
||
<?php echo lang("Or Reload the page");?>
|
||
</span>
|
||
<?php
|
||
}
|
||
?>
|
||
<!-- <input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label> -->
|
||
</div>
|
||
<div class="form-group col-md-4" style="padding: 20px;">
|
||
<?php
|
||
//AB
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5" || $q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "contrator" ){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right">
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
//C
|
||
if(($q_e_type->qualification_type == "4" || $q_e_type->qualification_type == "5") && $q_e_type->employee_type == "inhouse"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right">
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
?>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_dir_depo_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}
|
||
?>
|
||
</div>
|
||
</div>
|
||
<!-- 16-11-2021 -->
|
||
<?php /*
|
||
<div class="tab-pane disc_tab fade" id="doh-102-tab-dsc" 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(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('doh_102_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="documentType" value="Doh102">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<!-- for refrashing the pdf page -->
|
||
<input type="hidden" id="tab_specific_id" value="doh-102-tab">
|
||
<!-- for refrashing the pdf page -->
|
||
|
||
<!-- DOH 102 Form pdf -->
|
||
<div class="row pdf-form-container-doh-102-tab">
|
||
<?php $url=$user_folder."/"."DOH_CHRC102_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
|
||
<div class="col-lg-12 form-group pdf-form-doh-102-tab">
|
||
<embed
|
||
src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
|
||
type="application/pdf"
|
||
frameBorder="0"
|
||
scrolling="auto"
|
||
height="600px"
|
||
width="100%"
|
||
></embed>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<input type="hidden" name="signature" id="signature_final_field_doh_102_tab" value="">
|
||
<input type="hidden" name="date" id="signature_final_date_doh_102_tab" value="">
|
||
</div>
|
||
</div>
|
||
<!-- End of DOH 102 Form pdf -->
|
||
|
||
<hr class="mt-3">
|
||
<?php
|
||
if(!in_array("Doh102",$signature_type))
|
||
{
|
||
?>
|
||
<div id="date_signature_container_doh_102_tab">
|
||
<div class="row mt-3">
|
||
<div class="col-lg-6 form-group">
|
||
<label>Signature</label>
|
||
<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('doh_102_tab')" class="badge badge-info">Erasess</span></label>
|
||
<canvas class="form-control" id="signature_canvas_doh_102_tab" width="400" height="200" ></canvas>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" name="signature_field_date_doh_102_tab" id="signature_field_date_doh_102_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
<!-- <div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<input class="sigorwrite" type="checkbox" name="signature_type" id="doh_102_tab" value="write">
|
||
<label><b>Or Type Your Name</b></label>
|
||
<input type="text" class="form-control" id="signature_field_write_doh_102_tab" value="" disabled="">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" id="signature_field_date_write_doh_102_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
|
||
</div>
|
||
</div> -->
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="submit" name="submit" class="btn btn-info next_doh_102_tab" onclick="return signatureVal('doh_102_tab')"><?php echo lang('Save'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_doh_102_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}
|
||
?>
|
||
<div class="container-next" id="container_next_doh_102_tab">
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_doh_102_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
|
||
<div class="tab-pane disc_tab fade" id="doh-103-tab-dsc" 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(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('doh_103_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="documentType" value="Doh103">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<!-- for refrashing the pdf page -->
|
||
<input type="hidden" id="tab_specific_id" value="doh-103-tab">
|
||
<!-- for refrashing the pdf page -->
|
||
|
||
<!-- DOH 103 Form pdf -->
|
||
<div class="row pdf-form-container-doh-103-tab">
|
||
<?php $url=$user_folder."/"."DOH_CHRC103_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
|
||
<div class="col-lg-12 form-group pdf-form-doh-103-tab">
|
||
<embed
|
||
src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
|
||
type="application/pdf"
|
||
frameBorder="0"
|
||
scrolling="auto"
|
||
height="600px"
|
||
width="100%"
|
||
></embed>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<input type="hidden" name="signature" id="signature_final_field_doh_103_tab" value="">
|
||
<input type="hidden" name="date" id="signature_final_date_doh_103_tab" value="">
|
||
</div>
|
||
</div>
|
||
<!-- End of DOH 103 Form pdf -->
|
||
|
||
<hr class="mt-3">
|
||
<?php
|
||
if(!in_array("Doh103",$signature_type))
|
||
{
|
||
?>
|
||
<div id="date_signature_container_doh_103_tab">
|
||
<div class="row mt-3">
|
||
<div class="col-lg-6 form-group">
|
||
<label>Signature</label>
|
||
<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('doh_103_tab')" class="badge badge-info">Erasess</span></label>
|
||
<canvas class="form-control" id="signature_canvas_doh_103_tab" width="400" height="200" ></canvas>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" name="signature_field_date_doh_103_tab" id="signature_field_date_doh_103_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
<!-- <div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<input class="sigorwrite" type="checkbox" name="signature_type" id="doh_103_tab" value="write">
|
||
<label><b>Or Type Your Name</b></label>
|
||
<input type="text" class="form-control" id="signature_field_write_doh_103_tab" value="" disabled="">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" id="signature_field_date_write_doh_103_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
|
||
</div>
|
||
</div> -->
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="submit" name="submit" class="btn btn-info next_doh_103_tab" onclick="return signatureVal('doh_103_tab')"><?php echo lang('Save'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_doh_103_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}
|
||
?>
|
||
<div class="container-next" id="container_next_doh_103_tab">
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="button" class="btn btn-info next_doh_103_tab"><?php echo lang('Next'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
|
||
<!-- 16-11-2021 -->
|
||
<div class="tab-pane disc_tab fade" id="reg-rel-tab-dsc" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
|
||
<!-- Registry Release pdf -->
|
||
<div class="row pdf-form-container-reg-rel-tab">
|
||
<?php $url=$user_folder."/"."REGISTRY_RELEASE_".str_pad($ion_id, 6,"0",STR_PAD_LEFT).".pdf"; ?>
|
||
<div class="col-lg-12 form-group pdf-form-reg-rel-tab">
|
||
<embed
|
||
src="<?php echo base_url()?><?php echo $url;?>#toolbar=0&scrollbar=0&navpanes=0&view=FitH"
|
||
type="application/pdf"
|
||
frameBorder="0"
|
||
scrolling="auto"
|
||
height="600px"
|
||
width="100%"
|
||
></embed>
|
||
</div>
|
||
</div>
|
||
<!-- End of Registry Release pdf -->
|
||
|
||
<hr class="mt-3">
|
||
<?php
|
||
if(!in_array("RegistryRelease",$signature_type)){
|
||
?>
|
||
<div id="date_signature_container_reg_rel_tab">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/saveDocumentSignature" onsubmit="return validateFormSig('reg_rel_tab')" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation disclosure-signature-signform">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="documentType" value="RegistryRelease">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<!-- for refrashing the pdf page -->
|
||
<input type="hidden" id="tab_specific_id" value="reg-rel-tab">
|
||
<!-- for refrashing the pdf page -->
|
||
|
||
<input type="hidden" name="signature" id="signature_final_field_reg_rel_tab" value="">
|
||
<input type="hidden" name="date" id="signature_final_date_reg_rel_tab" value="">
|
||
|
||
<div class="row mt-3">
|
||
<div class="col-lg-6 form-group">
|
||
<label>Signature</label>
|
||
<label class="pull-right"><span style="cursor: pointer" onclick="clearCanvas('reg_rel_tab')" class="badge badge-info">Erasess</span></label>
|
||
<canvas class="form-control" id="signature_canvas_reg_rel_tab" width="400" height="200" ></canvas>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" name="signature_field_date_reg_rel_tab" id="signature_field_date_reg_rel_tab" value="<?php echo date('m-d-Y'); ?> <?php echo date('H:i:s'); ?>" required readonly>
|
||
</div>
|
||
</div>
|
||
<hr>
|
||
<!-- <div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<input class="sigorwrite" type="checkbox" name="signature_type" id="reg_rel_tab" value="write">
|
||
<label><b>Or Type Your Name</b></label>
|
||
<input type="text" class="form-control" id="signature_field_write_reg_rel_tab" value="" disabled="">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label>Date</label>
|
||
<?php $now_time=date('Y-m-d'); ?>
|
||
<input type="datetime" class="form-control" id="signature_field_date_write_reg_rel_tab" value="<?php echo date('Y-m-d'); ?> <?php echo date('H:i:s'); ?>" disabled="">
|
||
</div>
|
||
</div> -->
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<button type="submit" name="submit" id="next_reg_rel_tab" class="btn btn-info" onclick="return signatureVal('reg_rel_tab')"><?php echo lang('Save'); ?></button>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<div class="row">
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/final_pdf" method="post" enctype="multipart/form-data" class="needs-validation">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash();?>" />
|
||
<input type="hidden" name="documentType" value="RegistryRelease">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<input type="hidden" name="cg_type" value="<?php echo $cg_type;?>" readonly>
|
||
|
||
<?php
|
||
//D
|
||
if(($q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "inhouse"){
|
||
if($d_type=="true"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank">
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}if($d_type=="false"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank" disabled>
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
}
|
||
?>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/send_approval" method="post" enctype="multipart/form-data" class="needs-validation" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="form_tab_status" value="12">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<input type="hidden" name="form_status" value="12">
|
||
<input type="hidden" name="ion_id" value="<?php echo $nurse->ion_user_id; ?>">
|
||
|
||
<div class="row">
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<?php
|
||
if($sigTabStatus==1){
|
||
?>
|
||
<input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<span class="required-field text-info">
|
||
<?php echo lang("Please Sign to the all Signature Panels before Print or Submit for Approval");?>
|
||
</span>
|
||
<?php
|
||
}
|
||
?>
|
||
<!-- <input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label> -->
|
||
</div>
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<?php
|
||
//D
|
||
if(($q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "inhouse"){
|
||
if($d_type=="true"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right">
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}if($d_type=="false"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right" disabled>
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
}
|
||
?>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
<?php
|
||
}
|
||
?>
|
||
<div class="container-next" id="container_next_reg_rel_tab">
|
||
<div class="row">
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/final_pdf" method="post" enctype="multipart/form-data" class="needs-validation">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash();?>" />
|
||
<input type="hidden" name="documentType" value="RegistryRelease">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
|
||
<input type="hidden" name="cg_type" value="<?php echo $cg_type;?>" readonly>
|
||
|
||
<?php
|
||
//D
|
||
if(($q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "inhouse"){
|
||
?>
|
||
<button type="submit" name="submit" id="next_" class="btn btn-info" formtarget="_blank" disabled>
|
||
<?php echo lang('Print Form');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
?>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="form-group col-md-12" style="padding: 20px;">
|
||
<form role="form" action="<?php echo base_url(); ?>CaregiversDashboard/send_approval" method="post" enctype="multipart/form-data" class="needs-validation" >
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="form_tab_status" value="12">
|
||
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
|
||
<input type="hidden" name="form_status" value="12">
|
||
<input type="hidden" name="ion_id" value="<?php echo $nurse->ion_user_id; ?>">
|
||
|
||
<div class="row">
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<?php
|
||
if($sigTabStatus==1){
|
||
?>
|
||
<input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label>
|
||
<?php
|
||
}else{
|
||
?>
|
||
<span class="required-field text-info">
|
||
<?php echo lang("Please Sign to the all Signature Panels before Print or Submit for Approval");?>
|
||
</span>
|
||
<br>
|
||
<span class="text-info">
|
||
<?php echo lang("Or Reload the page");?>
|
||
</span>
|
||
<?php
|
||
}
|
||
?>
|
||
<!-- <input class="" type="checkbox" name="agree" id="agree" value="1">
|
||
<label class="" for="agree">I agree to the Terms and Conditions</label> -->
|
||
</div>
|
||
<div class="form-group col-md-6" style="padding: 20px;">
|
||
<?php
|
||
//D
|
||
if(($q_e_type->qualification_type == "6" || $q_e_type->qualification_type == "7") && $q_e_type->employee_type == "inhouse"){
|
||
?>
|
||
<button type="submit" name="submit" id="agreeSubmit" class="btn btn-success float-right">
|
||
<?php echo lang('Submit For Approval');?>
|
||
</button>
|
||
<?php
|
||
}
|
||
?>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<!-- 16-11-2021 -->
|
||
*/ ?>
|
||
</div>
|
||
|
||
<div class="tab-content loading-content">
|
||
<div class="w-100 ms-auto pt-4 pb-4">
|
||
<div class="text-center pb-1">
|
||
<img src="<?=base_url()?>common/assets/images/cupertino_activity_indicator_large.gif">
|
||
</div>
|
||
<h5 class="text-center timeCount-disclosure"></h5>
|
||
<h4 class="text-center text-info">Don't Reload the Page</h4>
|
||
<p class="text-center p-0 m-0 timeCount-disclosure-next">Please Wait We Are Creating Files...</p>
|
||
<h6 class="text-center">
|
||
<small>MAKE SURE YOU HAVE A STRONG INTERNATE CONNECTION!!</small>
|
||
</h6>
|
||
</div>
|
||
</div>
|
||
<!-- Ending of Disclosure Tabs Content Section -->
|
||
|
||
|
||
|
||
|
||
<!-- Modal box for filling information in pdf -->
|
||
|
||
<div class="modal fade" id="infoModal" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
|
||
<div class="modal-dialog modal-lg" role="document">
|
||
<div class="modal-content">
|
||
<div class="modal-header">
|
||
<h5 class="modal-title" id="exampleModalLabel"><?php echo lang("Fill Information");?></h5>
|
||
<div class="bg-lg m-auto">
|
||
<button type="button" class="close" data-dismiss="modal">×</button>
|
||
</div>
|
||
</div>
|
||
<div class="modal-body px-3">
|
||
<div id="card_1">
|
||
<form role="form" action="<?php echo base_url()?>CaregiversDashboard/ExtraPdfInfo" method="post" enctype="multipart/form-data" name="newGenInfo" class="disclosure-signature-extra-info-form">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="caregiverId" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
<input type="hidden" name="documentType" value="ContractorAgreement">
|
||
<input type="hidden" class="get-class" value="con-agree-tab">
|
||
|
||
<?php if($extraPdfInfo['ContractorAgreement']){$con_agree=json_decode($extraPdfInfo['ContractorAgreement']);}?>
|
||
<div class="form-group">
|
||
<label for="jhgjkkjh" class="col-form-label"><?php echo lang("Do you agree with the terms of this agreement?");?></label> 
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="agreement_checkbox_yes">Yes </label>
|
||
<input class="form-check-input" type="radio" name="checkbox_agree" id="agreement_checkbox_yes" value="yes"
|
||
<?php if($con_agree->checkbox_agree){if($con_agree->checkbox_agree=="yes"){echo "checked";}}?>>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="agreement_checkbox_no">No </label>
|
||
<input class="form-check-input" type="radio" name="checkbox_agree" id="agreement_checkbox_no" value="no"
|
||
<?php if($con_agree->checkbox_agree){if($con_agree->checkbox_agree=="no"){echo "checked";}}?>>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="title" class="col-form-label"><?php echo lang("Title");?></label>
|
||
<input type="text" class="form-control" id="title" name="title" value="<?php if($con_agree->title){echo $con_agree->title;}?>">
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="federal_id" class="col-form-label"><?php echo lang("Federal ID Number");?></label>
|
||
<input type="text" class="form-control" id="federal_id" name="federal_id" value="<?php if($con_agree->federal_id){echo $con_agree->federal_id;}?>">
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group mt-2 center-y">
|
||
<button type="submit" class="btn btn-primary" id="submitBtn" class="btn btn-info">
|
||
<?php echo lang('Update'); ?>
|
||
</button>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<div id="card_2">
|
||
<form role="form" action="<?php echo base_url()?>CaregiversDashboard/ExtraPdfInfo" method="post" enctype="multipart/form-data" name="newGenInfo" class="disclosure-signature-extra-info-form">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="caregiverId" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
<input type="hidden" name="documentType" value="BackgroundCheck">
|
||
<input type="hidden" class="get-class" value="bak-check-tab">
|
||
|
||
<?php $bak_check=json_decode($extraPdfInfo['BackgroundCheck']);?>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<label for="auth_check_other_name" class="col-form-label"><?php echo lang("Maiden/Other Names");?></label>
|
||
<input type="text" class="form-control" id="auth_check_other_name" name="auth_check_other_name"
|
||
value="<?php if($bak_check->auth_check_other_name){echo $bak_check->auth_check_other_name;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label for="auth_check_years_used" class="col-form-label"><?php echo lang("Years Used");?></label>
|
||
<input type="number" class="form-control" id="auth_check_years_used" name="auth_check_years_used"
|
||
value="<?php if($bak_check->auth_check_years_used){echo $bak_check->auth_check_years_used;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="background_check_report" class="col-form-label">
|
||
<span style="font-weight: bold;"><?php echo lang("If you live or work for the Company in California, Minnesota or Oklahoma:");?></span>
|
||
<span><?php echo lang("Check this box if you would like a free copy of your background check report:");?></span>
|
||
</label>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="checkbox" id="background_check_report" name="background_check_report" value="yes"
|
||
<?php if($bak_check->background_check_report){if($bak_check->background_check_report=="yes"){echo "checked";}}?>>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<label for="driver_license" class="col-form-label"><?php echo lang("Driver’s License Number");?></label>
|
||
<input type="text" class="form-control" id="driver_license" name="driver_license"
|
||
value="<?php if($bak_check->driver_license){echo $bak_check->driver_license;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label for="state_issuing_license" class="col-form-label"><?php echo lang("State Issuing License");?></label>
|
||
<input type="text" class="form-control" id="state_issuing_license" name="state_issuing_license"
|
||
value="<?php if($bak_check->state_issuing_license){echo $bak_check->state_issuing_license;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<span style="font-weight:bold;"><?php echo lang("Enter Any Other Names Used (including maiden names):");?></span>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_first_name1" class="col-form-label"><?php echo lang("First Name");?></label>
|
||
<input type="text" class="form-control" id="other_first_name1" name="other_first_name1"
|
||
value="<?php if($bak_check->other_first_name1){echo $bak_check->other_first_name1;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_middle_name1" class="col-form-label"><?php echo lang("Middle Name");?></label>
|
||
<input type="text" class="form-control" id="other_middle_name1" name="other_middle_name1"
|
||
value="<?php if($bak_check->other_middle_name1){echo $bak_check->other_middle_name1;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_last_name1" class="col-form-label"><?php echo lang("Last Name");?></label>
|
||
<input type="text" class="form-control" id="other_last_name1" name="other_last_name1"
|
||
value="<?php if($bak_check->other_last_name1){echo $bak_check->other_last_name1;}?>">
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_first_name2" class="col-form-label"><?php echo lang("First Name");?></label>
|
||
<input type="text" class="form-control" id="other_first_name2" name="other_first_name2"
|
||
value="<?php if($bak_check->other_first_name2){echo $bak_check->other_first_name2;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_middle_name2" class="col-form-label"><?php echo lang("Middle Name");?></label>
|
||
<input type="text" class="form-control" id="other_middle_name2" name="other_middle_name2"
|
||
value="<?php if($bak_check->other_middle_name2){echo $bak_check->other_middle_name2;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_last_name2" class="col-form-label"><?php echo lang("Last Name");?></label>
|
||
<input type="text" class="form-control" id="other_last_name2" name="other_last_name2"
|
||
value="<?php if($bak_check->other_last_name2){echo $bak_check->other_last_name2;}?>">
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_first_name3" class="col-form-label"><?php echo lang("First Name");?></label>
|
||
<input type="text" class="form-control" id="other_first_name3" name="other_first_name3"
|
||
value="<?php if($bak_check->other_first_name3){echo $bak_check->other_first_name3;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_middle_name3" class="col-form-label"><?php echo lang("Middle Name");?></label>
|
||
<input type="text" class="form-control" id="other_middle_name3" name="other_middle_name3"
|
||
value="<?php if($bak_check->other_middle_name3){echo $bak_check->other_middle_name3;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="other_last_name3" class="col-form-label"><?php echo lang("Last Name");?></label>
|
||
<input type="text" class="form-control" id="other_last_name3" name="other_last_name3"
|
||
value="<?php if($bak_check->other_last_name3){echo $bak_check->other_last_name3;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_address_details" class="col-form-label">
|
||
<span style="font-weight:bold;"><?php echo lang("Addresses Within The Past Seven Years (use a separate sheet as needed):");?></span>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<label for="prior_street_address1" class="col-form-label"><?php echo lang("Prior Street Address");?></label>
|
||
<input type="text" class="form-control" id="prior_street_address1" name="prior_street_address1"
|
||
value="<?php if($bak_check->prior_street_address1){echo $bak_check->prior_street_address1;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="from_date1" class="col-form-label"><?php echo lang("From");?></label>
|
||
<input type="date" class="form-control not_future" id="from_date1" name="from_date1" data-error="Please enter a valid date" value="<?php if($bak_check->from_date1){echo $bak_check->from_date1;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="to_date1" class="col-form-label"><?php echo lang("To");?></label>
|
||
<input type="date" class="form-control not_future" id="to_date1" name="to_date1" data-error="Please enter a valid date"
|
||
value="<?php if($bak_check->to_date1){echo $bak_check->to_date1;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="city_state_zip2" class="col-form-label"><?php echo lang("City/State/ZIP");?></label>
|
||
<input type="text" class="form-control" id="city_state_zip2" name="city_state_zip2"
|
||
value="<?php if($bak_check->city_state_zip2){echo $bak_check->city_state_zip2;}?>">
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<label for="prior_street_address2" class="col-form-label"><?php echo lang("Prior Street Address");?></label>
|
||
<input type="text" class="form-control" id="prior_street_address2" name="prior_street_address2"
|
||
value="<?php if($bak_check->prior_street_address2){echo $bak_check->prior_street_address2;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="from_date2" class="col-form-label"><?php echo lang("From");?></label>
|
||
<input type="date" class="form-control not_future" id="from_date2" name="from_date2" data-error="Please enter a valid date"
|
||
value="<?php if($bak_check->from_date2){echo $bak_check->from_date2;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="to_date2" class="col-form-label"><?php echo lang("To");?></label>
|
||
<input type="date" class="form-control not_future" id="to_date2" name="to_date2"
|
||
value="<?php if($bak_check->to_date2){echo $bak_check->to_date2;}?>">
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<label for="city_state_zip3" class="col-form-label"><?php echo lang("City/State/ZIP");?></label>
|
||
<input type="text" class="form-control" id="city_state_zip3" name="city_state_zip3"
|
||
value="<?php if($bak_check->city_state_zip3){echo $bak_check->city_state_zip3;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group mt-2 center-y">
|
||
<button type="submit" class="btn btn-primary" id="submitBtn" class="btn btn-info">
|
||
<?php echo lang('Update'); ?>
|
||
</button>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<div id="card_3">
|
||
<form role="form" action="<?php echo base_url()?>CaregiversDashboard/ExtraPdfInfo" method="post" enctype="multipart/form-data" name="newGenInfo" class="disclosure-signature-extra-info-form">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="caregiverId" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
<input type="hidden" name="documentType" value="iNineForm">
|
||
<input type="hidden" class="get-class" value="i-nine-tab">
|
||
|
||
<?php $i_nine=json_decode($extraPdfInfo['iNineForm']);?>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<label for="other_last_name" class="col-form-label"><?php echo lang("Other Last Names Used (if any)");?></label>
|
||
<input type="text" class="form-control" id="other_last_name" name="other_last_name"
|
||
value="<?php if($i_nine->other_last_name){echo $i_nine->other_last_name;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<span style="font-weight:bold;">
|
||
<?php echo lang("I attest, under penalty of perjury, that I am (check one of the following boxes)");?>
|
||
</span>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="country_citizen" id="country_citizen_citizen" value="citizen"
|
||
<?php if($i_nine->country_citizen){if($i_nine->country_citizen=="citizen"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="country_citizen_citizen"> 1. A citizen of the United States</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="country_citizen" id="country_citizen_non_citizen" value="non_citizen"
|
||
<?php if($i_nine->country_citizen){if($i_nine->country_citizen=="non_citizen"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="country_citizen_non_citizen"> 2. A noncitizen national of the United States (See instructions)</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="country_citizen" id="country_citizen_lawful_citizen" value="lawful_citizen" <?php if($i_nine->country_citizen){if($i_nine->country_citizen=="lawful_citizen"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="country_citizen_lawful_citizen"> 3. A lawful permanent resident</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="country_citizen_lawful_citizen">(Alien Registration Number/USCIS Number):</label>
|
||
<input type="text" class="form-control" id="uscis_no" name="uscis_no"
|
||
value="<?php if($i_nine->uscis_no){echo $i_nine->uscis_no;}?>">
|
||
</div>
|
||
|
||
<div class="col-lg-6 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="country_citizen" id="country_citizen_alien_authorized" value="alien_authorized" <?php if($i_nine->country_citizen){if($i_nine->country_citizen=="alien_authorized"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="country_citizen_alien_authorized"> 4. An alien authorized to work</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="alien_authorized_expire_date">until (expiration date, if applicable):</label>
|
||
<input type="date" class="form-control" id="alien_authorized_expire_date" name="alien_authorized_expire_date"
|
||
value="<?php if($i_nine->alien_authorized_expire_date){echo $i_nine->alien_authorized_expire_date;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<span style="font-weight:bold;">
|
||
<?php echo lang("Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:");?>
|
||
</span>
|
||
<span style="font-weight:bold;">
|
||
<?php echo lang("An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.");?>
|
||
</span>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="alien_uscis_no">1. Alien Registration Number/USCIS Number: </label>
|
||
<input class="form-check-input" type="text" name="alien_uscis_no" id="alien_uscis_no"
|
||
value="<?php if($i_nine->alien_uscis_no){echo $i_nine->alien_uscis_no;}?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-12 form-group center">OR</div>
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="form_I_94_no">2. Form I-94 Admission Number: </label>
|
||
<input class="form-check-input" type="text" name="form_I_94_no" id="form_I_94_no"
|
||
value="<?php if($i_nine->form_I_94_no){echo $i_nine->form_I_94_no;}?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-12 form-group center">OR</div>
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="foreign_passport_no">3. Foreign Passport Number: </label>
|
||
<input class="form-check-input" type="text" name="foreign_passport_no" id="foreign_passport_no"
|
||
value="<?php if($i_nine->foreign_passport_no){echo $i_nine->foreign_passport_no;}?>">
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<label class="form-check-label" for="county_issuance">Country of Issuance: </label>
|
||
<input class="form-check-input" type="text" name="county_issuance" id="county_issuance"
|
||
value="<?php if($i_nine->county_issuance){echo $i_nine->county_issuance;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<h4 style="font-weight:bold;">
|
||
<?php echo lang("Preparer and/or Translator Certification (check one):");?>
|
||
</h4>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="translator_use" id="translator_use_no" value="no"
|
||
<?php if($i_nine->translator_use){if($i_nine->translator_use=="no"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="translator_use_no"> I did not use a preparer or translator</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="translator_use" id="translator_use_yes" value="yes"
|
||
<?php if($i_nine->translator_use){if($i_nine->translator_use=="yes"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="translator_use_yes">
|
||
A preparer(s) and/or translator(s) assisted the employee in completing Section 1
|
||
</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<span style="font-weight:bold;">
|
||
<?php echo lang("I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.");?>
|
||
</span>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="translator_last_name">Last Name (Family Name)</label>
|
||
<input type="text" class="form-control" id="translator_last_name" name="translator_last_name"
|
||
value="<?php if($i_nine->translator_last_name){echo $i_nine->translator_last_name;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="translator_first_name">First Name (Given Name) </label>
|
||
<input type="text" class="form-control" id="translator_first_name" name="translator_first_name"
|
||
value="<?php if($i_nine->translator_first_name){echo $i_nine->translator_first_name;}?>">
|
||
</div>
|
||
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="translator_street">Address (Street Number and Name)</label>
|
||
<input type="text" class="form-control" id="translator_street" name="translator_street"
|
||
value="<?php if($i_nine->translator_street){echo $i_nine->translator_street;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="translator_city">City or Town</label>
|
||
<input type="text" class="form-control" id="translator_city" name="translator_city"
|
||
value="<?php if($i_nine->translator_city){echo $i_nine->translator_city;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="translator_state">State</label>
|
||
<input type="text" class="form-control" id="translator_state" name="translator_state"
|
||
value="<?php if($i_nine->translator_state){echo $i_nine->translator_state;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label class="uscis_no" for="translator_zip">ZIP Code</label>
|
||
<input type="text" class="form-control" id="translator_zip" name="translator_zip"
|
||
value="<?php if($i_nine->translator_zip){echo $i_nine->translator_zip;}?>">
|
||
</div>
|
||
|
||
<div class="col-lg-12 form-group">
|
||
<label class="uscis_no" for="review_immigration_status">Citizenship/Immigration Status</label>
|
||
<input type="text" class="form-control" id="review_immigration_status" name="review_immigration_status"
|
||
value="<?php if($i_nine->review_immigration_status){echo $i_nine->review_immigration_status;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group mt-2 center-y">
|
||
<button type="submit" class="btn btn-primary" id="submitBtn" class="btn btn-info">
|
||
<?php echo lang('Update'); ?>
|
||
</button>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<div id="card_4">
|
||
<form role="form" action="<?php echo base_url()?>CaregiversDashboard/ExtraPdfInfo" method="post" enctype="multipart/form-data" name="newGenInfo" class="disclosure-signature-extra-info-form">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="caregiverId" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
<input type="hidden" name="documentType" value="wNineForm">
|
||
<input type="hidden" class="get-class" value="w-nine-tab">
|
||
|
||
|
||
<?php $w_nine=json_decode($extraPdfInfo['wNineForm']);?>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<label for="business_name" class="col-form-label">
|
||
<?php echo lang("2. Business name/disregarded entity name, if different from above");?>
|
||
</label>
|
||
<input type="text" class="form-control" id="business_name" name="businessName"
|
||
value="<?php if($w_nine->businessName){echo $w_nine->businessName;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<span style="font-weight:bold;">
|
||
<?php echo lang("3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. ");?>
|
||
</span>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="tax_classification" id="tax_classification_individual" value="individual" <?php if($w_nine->tax_classification){if($w_nine->tax_classification=="individual"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="tax_classification_individual"> Individual/sole proprietor or single-member LLC</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="tax_classification" id="tax_classification_c_corporation" value="c_corporation" <?php if($w_nine->tax_classification){if($w_nine->tax_classification=="c_corporation"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="tax_classification_c_corporation"> C Corporation</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="tax_classification" id="tax_classification_s_corporation" value="s_corporation" <?php if($w_nine->tax_classification){if($w_nine->tax_classification=="s_corporation"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="tax_classification_s_corporation"> S Corporation</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="tax_classification" id="tax_classification_partnership" value="partnership" <?php if($w_nine->tax_classification){if($w_nine->tax_classification=="partnership"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="tax_classification_partnership"> Partnership</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-4 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="tax_classification" id="tax_classification_estate" value="estate"
|
||
<?php if($w_nine->tax_classification){if($w_nine->tax_classification=="estate"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="tax_classification_estate"> Trust/estate</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-8 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="tax_classification" id="tax_classification_liability" value="liability"
|
||
<?php if($w_nine->tax_classification){if($w_nine->tax_classification=="liability"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="tax_classification_liability"> Limited liability company</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="tax_classification" id="tax_classification_other" value="other"
|
||
<?php if($w_nine->tax_classification){if($w_nine->tax_classification=="other"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="tax_classification_other"> Other (see instructions)</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<span style="font-weight:bold;">
|
||
<?php echo lang("4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):");?>
|
||
</span>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-5 form-group">
|
||
<label for="exempt_payee_code" class="col-form-label"><?php echo lang("Exempt payee code (if any)");?></label>
|
||
<input type="text" class="form-control" id="exempt_payee_code" name="exempt_payee_code"
|
||
value="<?php if($w_nine->exempt_payee_code){echo $w_nine->exempt_payee_code;}?>">
|
||
</div>
|
||
<div class="col-lg-7 form-group">
|
||
<label for="exempt_reporting_code" class="col-form-label"><?php echo lang("Exemption from FATCA reporting code (if any)");?></label>
|
||
<input type="text" class="form-control" id="exempt_reporting_code" name="exempt_reporting_code"
|
||
value="<?php if($w_nine->exempt_reporting_code){echo $w_nine->exempt_reporting_code;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<label for="list_account_no" class="col-form-label"><?php echo lang("7. List account number(s) here (optional)");?></label>
|
||
<input type="text" class="form-control" id="list_account_no" name="list_account_no"
|
||
value="<?php if($w_nine->list_account_no){echo $w_nine->list_account_no;}?>">
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<label for="requester_optional_name_address" class="col-form-label"><?php echo lang("Requester’s name and address (optional)");?></label>
|
||
<input type="text" class="form-control" id="requester_optional_name_address" name="requester_optional_name_address"
|
||
value="<?php if($w_nine->requester_optional_name_address){echo $w_nine->requester_optional_name_address;}?>">
|
||
</div>
|
||
<div class="col-lg-12 form-group">
|
||
<label for="emp_id" class="col-form-label"><?php echo lang("Employer Identification number");?></label>
|
||
<input type="text" class="form-control" id="emp_id" name="emp_id"
|
||
value="<?php if($w_nine->emp_id){echo $w_nine->emp_id;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group mt-2 center-y">
|
||
<button type="submit" class="btn btn-primary" id="submitBtn" class="btn btn-info">
|
||
<?php echo lang('Update'); ?>
|
||
</button>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
<div id="card_5">
|
||
<form role="form" action="<?php echo base_url()?>CaregiversDashboard/ExtraPdfInfo" method="post" enctype="multipart/form-data" name="newGenInfo" class="disclosure-signature-extra-info-form">
|
||
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
|
||
<input type="hidden" name="caregiverId" value="<?php if (!empty($nurse->id)) echo $nurse->id; ?>">
|
||
<input type="hidden" name="documentType" value="DirectDiposit">
|
||
<input type="hidden" class="get-class" value="dir-depo-tab">
|
||
|
||
<?php $dir_depo=json_decode($extraPdfInfo['DirectDiposit']);?>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<h4 style="font-weight:bold;">
|
||
<?php echo lang("Account #1");?>
|
||
</h4>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<label for="jhgjkkjh" class="col-form-label"><?php echo lang("Account #1 Type (check one):");?></label> 
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="account1_type" id="account1_type_checking" value="checking"
|
||
<?php if($dir_depo->account1_type){if($dir_depo->account1_type=="checking"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="account1_type_checking"> Checking</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="account1_type" id="account1_type_saving" value="saving"
|
||
<?php if($dir_depo->account1_type){if($dir_depo->account1_type=="saving"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="account1_type_saving"> Savings</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label for="account1_employee_bank_name" class="col-form-label"><?php echo lang("Employee Bank Name");?></label>
|
||
<input type="text" class="form-control" id="account1_employee_bank_name" name="account1_employee_bank_name"
|
||
value="<?php if($dir_depo->account1_employee_bank_name){echo $dir_depo->account1_employee_bank_name;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label for="account1_bank_routing_account" class="col-form-label"><?php echo lang("Bank Routing# (ABA#) Account# ");?></label>
|
||
<input type="text" class="form-control" id="account1_bank_routing_account" name="account1_bank_routing_account"
|
||
value="<?php if($dir_depo->account1_bank_routing_account){echo $dir_depo->account1_bank_routing_account;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group">
|
||
<label for="other_details" class="col-form-label">
|
||
<h4 style="font-weight:bold;">
|
||
<?php echo lang("Account #2 (remainder to be deposited to this account)");?>
|
||
</h4>
|
||
</label>
|
||
<div class="row">
|
||
<div class="col-lg-12 form-group">
|
||
<label for="jhgjkkjh" class="col-form-label"><?php echo lang("Account #2 Type (check one):");?></label> 
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="account2_type" id="account2_type_checking" value="checking"
|
||
<?php if($dir_depo->account2_type){if($dir_depo->account2_type=="checking"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="account2_type_checking"> Checking</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" type="radio" name="account2_type" id="account2_type_saving" value="saving"
|
||
<?php if($dir_depo->account2_type){if($dir_depo->account2_type=="saving"){echo "checked";}}?>>
|
||
<label class="form-check-label" for="account2_type_saving"> Savings</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label for="account2_employee_bank_name" class="col-form-label"><?php echo lang("Employee Bank Name");?></label>
|
||
<input type="text" class="form-control" id="account2_employee_bank_name" name="account2_employee_bank_name"
|
||
value="<?php if($dir_depo->account2_employee_bank_name){echo $dir_depo->account2_employee_bank_name;}?>">
|
||
</div>
|
||
<div class="col-lg-6 form-group">
|
||
<label for="account2_bank_routing_account" class="col-form-label"><?php echo lang("Bank Routing# (ABA#) Account# ");?></label>
|
||
<input type="text" class="form-control" id="account2_bank_routing_account" name="account2_bank_routing_account"
|
||
value="<?php if($dir_depo->account2_bank_routing_account){echo $dir_depo->account2_bank_routing_account;}?>">
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<hr/>
|
||
<div class="form-group mt-2 center-y">
|
||
<button type="submit" class="btn btn-primary" id="submitBtn" class="btn btn-info">
|
||
<?php echo lang('Update'); ?>
|
||
</button>
|
||
</div>
|
||
</form>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<!-- Modal box for filling information in pdf -->
|
||
|
||
<!-- for canvas drawing signature -->
|
||
<script src="https://code.jquery.com/jquery-3.4.1.min.js" integrity="sha384-vk5WoKIaW/vJyUAd9n/wmopsmNhiy+L2Z+SBxGYnUkunIxVxAv/UtMOhba/xskxh" crossorigin="anonymous"></script>
|
||
<script src="<?php echo base_url(); ?>common/signature/drawing-table-multi.js" type="text/javascript"></script>
|
||
<!-- for canvas drawing signature -->
|
||
<!-- Scripts for Disclosure tabs content section -->
|
||
<script type="text/javascript">
|
||
$(document).ready(function(){
|
||
$(".container-next").hide();
|
||
});
|
||
</script>
|
||
<script type="text/javascript">
|
||
$(document).ready(function(){
|
||
$(".disclosure-signature-signform").submit(function(e) {
|
||
e.preventDefault(); // avoid to execute the actual submit of the form.
|
||
var form = $(this);
|
||
var url = form.attr('action');
|
||
|
||
// for refreshing the pdf files
|
||
var className=$(this).children("input#tab_specific_id").val();
|
||
var target=$(".pdf-form-container-"+className).children(".pdf-form-"+className);
|
||
var embed=target.children("embed");
|
||
var src=embed.attr("src");
|
||
// alert(src);
|
||
// for refreshing the pdf files
|
||
|
||
$.ajax({
|
||
type: "POST",
|
||
url: url,
|
||
data: form.serialize(), // serializes the form's elements.
|
||
beforeSend : function(){
|
||
$(".loading-content").show();
|
||
$(".disclosure-pdf-container,.disclosure-pdf-tabs").hide();
|
||
},
|
||
success: function(data)
|
||
{
|
||
if(data){
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'success',
|
||
title: 'Signature successfully saved.',
|
||
showConfirmButton: false,
|
||
timer: 2500
|
||
});
|
||
}
|
||
else{
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Some error occure please try again.',
|
||
showConfirmButton: false,
|
||
timer: 2500
|
||
});
|
||
}
|
||
$(".loading-content").hide();
|
||
$(".disclosure-pdf-container,.disclosure-pdf-tabs").show();
|
||
|
||
// for refreshing the pdf files
|
||
var emb='<embed src="'+src+'" height="600px" width="100%"></embed>';
|
||
target.html(emb);
|
||
// for refreshing the pdf files
|
||
|
||
//hide extra info edit modal calling button
|
||
$(".extra-info-pdf-"+className).hide();
|
||
//hide extra info edit modal calling button
|
||
|
||
}
|
||
});
|
||
});
|
||
});
|
||
</script>
|
||
<script type="text/javascript">
|
||
$(document).ready(function(){
|
||
var type=$("#cgType").val();
|
||
$(".next_app_emp_tab").click(function(){
|
||
$(".disc_tab").removeClass('active in show');
|
||
$(".doc_tab_top").removeClass('active');
|
||
if(type=="A"){
|
||
$("#con-agree-tab-dsc").addClass('active in show');
|
||
$("#con-agree-tab").addClass('active');
|
||
}if(type=="B"){
|
||
$("#con-agree-tab-dsc").addClass('active in show');
|
||
$("#con-agree-tab").addClass('active');
|
||
}if(type=="C"){
|
||
$("#bak-check-tab-dsc").addClass('active in show');
|
||
$("#bak-check-tab").addClass('active');
|
||
}if(type=="D"){
|
||
$("#bak-check-tab-dsc").addClass('active in show');
|
||
$("#bak-check-tab").addClass('active');
|
||
}
|
||
});
|
||
$(".next_con_agree_tab").click(function(){
|
||
var selector=$(".disclouser_tab.active").next('li');
|
||
$(".disclouser_tab").removeClass('active');
|
||
$(".disc_tab").removeClass('active in show');
|
||
selector.addClass('active');
|
||
var next_active_id='#'+selector.find('a').attr('id')+'-dsc';
|
||
$(next_active_id).addClass('active in show');
|
||
// $(".disc_tab").removeClass('active in show');
|
||
// $(".doc_tab_top").removeClass('active');
|
||
// if(type=="A"){
|
||
// $("#bak-check-tab-dsc").addClass('active in show');
|
||
// $("#bak-check-tab").addClass('active');
|
||
// }if(type=="B"){
|
||
// $("#bak-check-tab-dsc").addClass('active in show');
|
||
// $("#bak-check-tab").addClass('active');
|
||
// }
|
||
});
|
||
$(".next_bak_check_tab").click(function(){
|
||
$(".disc_tab").removeClass('active in show');
|
||
$(".doc_tab_top").removeClass('active');
|
||
if(type=="A"){
|
||
$("#i-nine-tab-dsc").addClass('active in show');
|
||
$("#i-nine-tab").addClass('active');
|
||
}if(type=="B"){
|
||
$("#i-nine-tab-dsc").addClass('active in show');
|
||
$("#i-nine-tab").addClass('active');
|
||
}if(type=="C"){
|
||
$("#i-nine-tab-dsc").addClass('active in show');
|
||
$("#i-nine-tab").addClass('active');
|
||
}if(type=="D"){
|
||
$("#i-nine-tab-dsc").addClass('active in show');
|
||
$("#i-nine-tab").addClass('active');
|
||
}
|
||
});
|
||
$(".next_i_nine_tab").click(function(){
|
||
var selector=$(".disclouser_tab.active").next("li");
|
||
$(".disclouser_tab").removeClass('active');
|
||
$(".disc_tab").removeClass('active in show');
|
||
selector.addClass('active');
|
||
var next_active_id='#'+selector.find('a').attr('id')+'-dsc';
|
||
$(next_active_id).addClass('active in show');
|
||
|
||
// $(".disc_tab").removeClass('active in show');
|
||
// $(".doc_tab_top").removeClass('active');
|
||
// if(type=="A"){
|
||
// $("#w-nine-tab-dsc").addClass('active in show');
|
||
// $("#w-nine-tab").addClass('active');
|
||
// }if(type=="B"){
|
||
// $("#w-nine-tab-dsc").addClass('active in show');
|
||
// $("#w-nine-tab").addClass('active');
|
||
// }if(type=="C"){
|
||
// $("#dir-depo-tab-dsc").addClass('active in show');
|
||
// $("#dir-depo-tab").addClass('active');
|
||
// }if(type=="D"){
|
||
// $("#dir-depo-tab-dsc").addClass('active in show');
|
||
// $("#dir-depo-tab").addClass('active');
|
||
// }
|
||
});
|
||
$(".next_w_nine_tab").click(function(){
|
||
var selector=$(".disclouser_tab.active").next("li");
|
||
$(".disclouser_tab").removeClass('active');
|
||
$(".disc_tab").removeClass('active in show');
|
||
selector.addClass('active');
|
||
var next_active_id='#'+selector.find('a').attr('id')+'-dsc';
|
||
$(next_active_id).addClass('active in show');
|
||
var url="<?=base_url();?>/onboarding/process/<?=$token?>";
|
||
window.location.href = url;
|
||
// $(".disc_tab").removeClass('active in show');
|
||
// $(".doc_tab_top").removeClass('active');
|
||
// if(type=="A"){
|
||
// $("#dir-depo-tab-dsc").addClass('active in show');
|
||
// $("#dir-depo-tab").addClass('active');
|
||
// }if(type=="B"){
|
||
// $("#dir-depo-tab-dsc").addClass('active in show');
|
||
// $("#dir-depo-tab").addClass('active');
|
||
// }
|
||
});
|
||
$(".next_dir_depo_tab").click(function(){
|
||
var selector=$(".disclouser_tab.active").next('li, .disclouser_tab');
|
||
$(".disclouser_tab").removeClass('active');
|
||
$(".disc_tab").removeClass('active in show');
|
||
selector.addClass('active');
|
||
var next_active_id='#'+selector.find('a').attr('id')+'-dsc';
|
||
$(next_active_id).addClass('active in show');
|
||
// if(type=="D"){
|
||
// $(".disc_tab").removeClass('active in show');
|
||
// $(".doc_tab_top").removeClass('active');
|
||
|
||
// $("#doh-102-tab-dsc").addClass('active in show');
|
||
// $("#doh-102-tab").addClass('active');
|
||
// }
|
||
});
|
||
$(".next_doh_102_tab").click(function(){
|
||
$(".disc_tab").removeClass('active in show');
|
||
$(".doc_tab_top").removeClass('active');
|
||
if(type=="D"){
|
||
$("#doh-103-tab-dsc").addClass('active in show');
|
||
$("#doh-103-tab").addClass('active');
|
||
}
|
||
});
|
||
$(".next_doh_103_tab").click(function(){
|
||
$(".disc_tab").removeClass('active in show');
|
||
$(".doc_tab_top").removeClass('active');
|
||
if(type=="D"){
|
||
$("#reg-rel-tab-dsc").addClass('active in show');
|
||
$("#reg-rel-tab").addClass('active');
|
||
}
|
||
});
|
||
|
||
});
|
||
</script>
|
||
<script type="text/javascript">
|
||
$(document).ready(function(){
|
||
$(".loading-content").hide();
|
||
// $("#disclouser_sign_ancore").click(function(){
|
||
var cg_id=$("#cg_id").val();
|
||
// var tabStat=<?php echo $tabstatus['doc']?>;
|
||
// if(tabStat==1 || tabStat==2){
|
||
hitDisclosureAjax(cg_id);
|
||
// }
|
||
// });
|
||
});
|
||
|
||
function hitDisclosureAjax(cg_id){
|
||
// alert('hitDisclosureAjax');
|
||
$.ajax({
|
||
url:"<?php echo base_url()?>CaregiversDashboard/disclosureAjax",
|
||
type:"GET",
|
||
data:{cg_id:cg_id},
|
||
// dataType: "json",
|
||
beforeSend : function(){
|
||
$(".loading-content").show();
|
||
$(".disclosure-pdf-container,.disclosure-pdf-tabs").hide();
|
||
|
||
//loading timer
|
||
$(".timeCount-disclosure-next").html("Please Wait We Are Creating Files...");
|
||
$(".timeCount-disclosure").show();
|
||
var targetTime=23;
|
||
var i=0;
|
||
var x = setInterval(function(){
|
||
var distance = targetTime-i;
|
||
$(".timeCount-disclosure").html(distance+"s");
|
||
if(distance<=0){
|
||
clearInterval(x);
|
||
$(".timeCount-disclosure-next").html("Files Are Ready Almost....");
|
||
$(".timeCount-disclosure").hide();
|
||
}
|
||
i++;
|
||
}, 1000);
|
||
//loading timer
|
||
|
||
},
|
||
success:function(data){
|
||
$(".loading-content").hide();
|
||
$(".disclosure-pdf-container,.disclosure-pdf-tabs").show();
|
||
}
|
||
});
|
||
}
|
||
</script>
|
||
<!-- Ending of Scripts for Disclosure tabs content section -->
|
||
|
||
<!-- Scripts for fill information madal box cards -->
|
||
<script type="text/javascript">
|
||
$('#infoModal').on('show.bs.modal', function (event) {
|
||
var button = $(event.relatedTarget);
|
||
var recipient = button.data('whatever');
|
||
var modal = $(this);
|
||
modal.find('.modal-title').text('New message to ' + recipient);
|
||
modal.find('.modal-body input').val(recipient);
|
||
});
|
||
$(document).ready(function(){
|
||
$("#card_1_edit").click(function(){
|
||
$("#card_1").show();
|
||
$("#card_1").siblings().hide();
|
||
});
|
||
$("#card_2_edit").click(function(){
|
||
$("#card_2").show();
|
||
$("#card_2").siblings().hide();
|
||
});
|
||
$("#card_3_edit").click(function(){
|
||
$("#card_3").show();
|
||
$("#card_3").siblings().hide();
|
||
});
|
||
$("#card_4_edit").click(function(){
|
||
$("#card_4").show();
|
||
$("#card_4").siblings().hide();
|
||
});
|
||
$("#card_5_edit").click(function(){
|
||
$("#card_5").show();
|
||
$("#card_5").siblings().hide();
|
||
});
|
||
$("#card_6_edit").click(function(){
|
||
$("#card_6").show();
|
||
$("#card_6").siblings().hide();
|
||
});
|
||
});
|
||
</script>
|
||
<!-- Scripts for fill information madal box cards -->
|
||
|
||
<script type="text/javascript">
|
||
$(document).ready(function(){
|
||
$(".disclosure-signature-extra-info-form").submit(function(e) {
|
||
e.preventDefault(); // avoid to execute the actual submit of the form.
|
||
var form = $(this);
|
||
var url = form.attr('action');
|
||
|
||
var className=$(this).children("input.get-class").val();
|
||
// alert(className);
|
||
|
||
$.ajax({
|
||
type: "POST",
|
||
url: url,
|
||
data: form.serialize(), // serializes the form's elements.
|
||
beforeSend : function(){
|
||
|
||
},
|
||
success: function(data)
|
||
{
|
||
if(data){
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'success',
|
||
title: 'New information added successfully',
|
||
showConfirmButton: false,
|
||
timer: 2500
|
||
});
|
||
}
|
||
else{
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Some error occure please try again.',
|
||
showConfirmButton: false,
|
||
timer: 2500
|
||
});
|
||
}
|
||
$("#infoModal").modal('hide');
|
||
// var className="w-nine-tab";
|
||
|
||
var src=$(".pdf-form-"+className).children("embed").attr("src");
|
||
var emb='<embed src="'+src+'" height="600px" width="100%"></embed>';
|
||
$(".pdf-form-"+className).html(emb);
|
||
}
|
||
});
|
||
});
|
||
});
|
||
</script>
|
||
|
||
<script type="text/javascript">
|
||
$(function(){
|
||
var today = new Date();
|
||
var dd = today.getDate();
|
||
var mm = today.getMonth()+1; //January is 0!
|
||
var yyyy = today.getFullYear();
|
||
if(dd<10){
|
||
dd='0'+dd
|
||
}
|
||
if(mm<10){
|
||
mm='0'+mm
|
||
}
|
||
|
||
today = yyyy+'-'+mm+'-'+dd;
|
||
$(".not_future").attr("max", today);
|
||
})
|
||
</script>
|
||
<!-- Document signature -->
|
||
<script type="text/javascript">
|
||
function signatureVal(id){
|
||
if(isCanvasBlanked(document.getElementById('signature_canvas_'+id))){
|
||
Swal.fire({
|
||
position: 'center',
|
||
icon: 'error',
|
||
title: 'Please sign the agreement.',
|
||
showConfirmButton: false,
|
||
timer: 1500
|
||
});
|
||
return false;
|
||
}
|
||
else{
|
||
return true;
|
||
}
|
||
}
|
||
function isCanvasBlanked(canvas) {
|
||
const context = canvas.getContext('2d');
|
||
const pixelBuffer = new Uint32Array(
|
||
context.getImageData(0, 0, canvas.width, canvas.height).data.buffer
|
||
);
|
||
return !pixelBuffer.some(color => color !== 0);
|
||
}
|
||
</script>
|
||
|
||
<script type="text/javascript">
|
||
function validateFormSig(id){
|
||
// alert(id);
|
||
if($("#"+id).is(":checked")){
|
||
var sig = $("#signature_field_write_"+id).val();
|
||
var dateSig = $("#signature_field_date_write_"+id).val();
|
||
$("#signature_final_field_"+id).val(sig);
|
||
$("#signature_final_date_"+id).val(dateSig);
|
||
}
|
||
else{
|
||
var canvas1 = document.getElementById('signature_canvas_'+id);
|
||
if(canvas1){
|
||
var signature=canvas1.toDataURL("image/png");
|
||
$("#signature_final_field_"+id).val(signature);
|
||
var dateSig = $("#signature_field_date_"+id).val();
|
||
$("#signature_final_date_"+id).val(dateSig);
|
||
}
|
||
}
|
||
$("#date_signature_container_"+id).hide();
|
||
$("#container_next_"+id).show();
|
||
}
|
||
function clearCanvas(id){
|
||
var cnvid = "signature_canvas_"+id;
|
||
var c = document.getElementById(cnvid);
|
||
var ctx = c.getContext("2d");
|
||
ctx.fillStyle = "red";
|
||
ctx.clearRect(0, 0, 400, 200);
|
||
}
|
||
</script>
|
||
<!-- Document signature -->
|
||
<?php
|
||
// }
|
||
?>
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|