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<?php ob_start(); include 'core/init.php'; error_reporting(0); $toDate = date_create() ->format("m/d/Y"); $myCurTime=$currentTime; $myLoc = $_GET['loc']; ?> <!DOCTYPE html> <html> <head> <meta name="viewport" content="width=device-width, initial-scale=1"> <link href='https://fonts.googleapis.com/css?family=Arial' rel='stylesheet'> <style> body, html { height: 100%; margin: 0; background:white; } .textRow{ margin-left:2%; font-size:110%; border:0px solid red; border-bottom:1px solid gray; padding-top:10px; width:45%; float:left; } .noPadding{ background: rgba(255, 255, 255, 1); border:0px solid red; max-width:100%; height:auto; padding:0px; } .divA{ float:left; width:25%; height:150px; border:0px solid red; background:white; } .divB{ float:left; width:50%; height:150px; border:0px solid red; background:white; } .divC{ float:left; width:25%; height:150px; border:0px solid red; background:white; } .MainDiv{ width:60%; min-height:700px; margin-left:20%; border:0px solid gray; border-radius:10px; height:auto; min-height:1000px; margin-top:10px; } .imgSRC{ float:left; margin:10px; margin-top:-25px; margin:0px; width:70%; text-align:center; } .contentA{ padding:25px; padding-top:10px; padding-bottom:30px; border:1px solid #fee492 ; width:85%; margin-left:5%; margin-bottom:20px; border-radius:5px; background:white; margin-top:20px; } .content{ padding:25px; padding-top:10px; padding-bottom:30px; border:1px solid #fee492 ; width:85%; margin-left:5%; margin-bottom:20px; border-radius:5px; background:white; margin-top:20px; } .MainDivBody{ float:left;width:100%; border:0px solid red; margin-bottom:50px; background:#e9e4df; border-radius:5px; } @media only screen and (max-width:1200px) { /* For mobile phones: / .MainDiv{ width:80%; margin-left:10%; border:0px solid red; margin-left:10%; border:1px solid gray; border-radius:10px; height:auto; margin-top:10px; } .imgSRC{ float:left; margin:10px; margin-top:-25px; margin:0px; width:50%; align:center; } .contentA{ padding:25px; padding-top:10px; padding-bottom:30px; border:1px solid #fee492 ; width:85%; margin-left:5%; margin-bottom:20px; border-radius:5px; background:white; margin-top:20px; } .MainDivBody{ float:left; width:96%; border:0px solid red; margin-bottom:50px; background:#e9e4df; border-radius:5px; padding:2%; } @media only screen and (max-width:800px) { / For mobile phones: / .textRow{ float:left; font-size:110%; border:0px solid red; border-bottom:1px solid gray; padding-top:10px; width:100%; margin-left:0px; } .noPadding{ position:relative; background: rgba(255, 255, 255, 1); border:0px solid red; height:100%; padding:0px; width:100%; margin:0px; } .divA{ float:left; width:100%; height:150px; border:0px solid red; background:white; } .divB{ float:left; width:100%; height:150px; border:0px solid red; background:white; } .divC{ float:left; display:none; width:100%; height:150px; border:0px solid red; background:white; } .MainDiv{ width:100%; margin-left:.5%; border:0px solid PINK; border-radius:0px; height:auto; min-height:1000px; margin-top:10px; } .imgSRC{ float:left; margin:10px; margin-top:-25px; margin:0px; width:50%; align:center; margin-left:25%; } } .content{ padding:5px; padding-top:10px; padding-bottom:30px; border:0px solid #fee492 ; width:96%; margin-left:.5%; margin-bottom:20px; border-radius:5px; background:white; margin-top:20px; } .contentA{ padding:5px; padding-top:10px; padding-bottom:30px; border:0px solid #fee492 ; width:96%; margin-left:.5%; margin-bottom:20px; border-radius:5px; background:white; margin-top:20px; height:430px; } .MainDivBody{ float:left; width:96%; border:0px solid red; margin-bottom:50px; background:#e9e4df; border-radius:5px; padding:2%; } </style> </head> <script type="text/javascript"> function redirect() { var url = "http://www.(url).com"; window.location(url); } </script> <body> <div style="background:transparent; padding:0px;border:0px solid red; width:100%;padding-bottom:50px;height:auto"> <div class="MainDiv"> <div class="divA"> <img class="imgSRC" src="autohub_logo.png"></img> </div> <div class="divB"> <p style="text-align:center;font-family:Arial;font-size:200%;font-weight:normal">AUTOHUB Contact Tracing and Health Declaration Form.3 <input type="text" id="myLoc" style="border:1px solid white;text-align:center" readonly value="<?php echo $myLoc;?>"></p> </p> </div> <div class="divC" > </div> <div class="MainDivBody" > <div class="content"> <p style="padding:20px;font-family:Arial;font-size:110%;font-weight:normal;text-align:justify;padding-top:0px"> <p style="padding:20px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify"> Kindly take a few moments to complete this form as it will help us to get in touch with you in the unlikely event that contact tracing is required. All employees are required to complete this form prior to entering the AUTOHUB facility. </p> <p style="padding:20px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:red"> Required</p> </div> <div class="content"> <input type="hidden" id="toDate" value="<?php echo $toDate;?>"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Work Schedule; <b style="font-size:14px;color:red"></b></p> <input type="text" id="workSched" value="" placeholder="Schedule (M,W,F / T,TH,S) " style="font-size:110%;border:0px solid red;border-bottom:0px solid gray;padding-top:0px;width:50%"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Temperature <b style="font-size:14px;color:red"></b></p> <input type="text" id="myTemp" value="" placeholder="You Answer" style="font-size:120%;border:0px solid red;border-bottom:0px solid gray;padding-top:0px;width:50%"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Department<b style="font-size:14px;color:red">:</b></p> <input type="text" id="empDept" required placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Position<b style="font-size:14px;color:red">:</b></p> <input type="text" id="empPosition" required placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Dealership Location<b style="font-size:14px;color:red">:</b></p> <input type="text" id="dealership" required placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Employee's Last name <b style="font-size:14px;color:red">:</b></p> <input type="text" id="empLastName" required placeholder="Your Answer" style="font-size:110%;font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Employee's First name <b style="font-size:14px;color:red">:</b></p> <input type="text" id="empFirstName" required placeholder="Your Answer" style="font-size:110%;font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">Do you live inside a declared COVID 19 locked down area after March 17, 2020?<b style="font-size:14px;color:red">:</b></p> <label for="LiveInsideNo" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="LiveInsideNo" checked name="noLiveInsideYes" value="no"> No </label><br><br> <label for="LiveInsideYes" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="LiveInsideYes" name="noLiveInsideYes" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">If yes, please provide the following information:</p> <input type="text" id="brgy" required placeholder="Barangay" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> <input type="text" id="town" required placeholder="Town" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> <input type="text" id="province" required placeholder="Provice" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> <input type="text" id="city" required placeholder="City" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> <br><br><p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">Proximity distance of COVID 19 positive res to your home:</p> <input type="text" id="distance" required placeholder="Distance" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Have you been in close contact with a person diagnosed with, or suspected of being infected by, COVID-19? <b style="font-size:14px;color:red">:</b></p> <label for="closeContactNo" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" checked id="closeContactNo" name="closeContact" value="no"> No </label><br><br> <label for="closeContactYes" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="closeContactYes" name="closeContact" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">What is your relationship with this person:</p> <input type="text" id="relationshipWithContact" placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Do you live in the same home? <b style="font-size:14px;color:red">:</b></p> <label for="liveSameHomeNo" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" checked id="liveSameHomeNo" name="liveSameHome" value="no"> No </label><br><br> <label for="liveSameHomeYes" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="liveSameHomeYes" name="liveSameHome" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px"> When was the last date of contact?</p> <input type="text" id="lastDateOfContact" placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">Have you been in the hospital or health care facility in the past 7 days?<b style="font-size:14px;color:red">:</b></p> <label for="hospitalNo" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" checked id="hospitalNo" name="hospital" value="no"> No </label><br><br> <label for="hospitalYes" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="hospitalYes" name="hospital" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">If yes, State your purpose, date and time:</p> <input type="text" id="hospitalPurpose" placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">Have you travelled to another County, Region, and Province?<b style="font-size:14px;color:red">:</b></p> <label for="travelNo" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" checked id="travelNo" name="travel" value="no"> No </label><br><br> <label for="travelYes" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="travelYes" name="travel" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">If Yes, State the location and date of travel:</p> <input type="text" id="travelLocation" required placeholder="Location" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> <input type="date" id="travelDate" required placeholder="Travel Date" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Have you experience any signs and symptoms (fever, chills, sore throat, runny rose, cough, shortness of breath) prior to your visit to our facility?<b style="font-size:14px;color:red"></b></p> <label for="symptomsNo" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" checked id="symptomsNo" name="symptoms" value="no"> No </label><br><br> <label for="symptomsYes" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="symptomsYes" name="symptoms" value="yes"> Yes </label><br> <br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">Date the symptoms first appeared:</p> <input type="date" id="symptomsDate" required placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Have you been to this areas other than office / home in the last 7 days?<b style="font-size:14px;color:red">:</b></p> <select id="visitedPlaces" style="font-size:110%;font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> <option value="NA">NA</option> <option value="Market">Market</option> <option value="Malls">Malls</option> <option value="Grocery">Grocery</option> <option value="Church">Church</option> <option value="Bank">Bank</option> <option value="BayadCenter">Bayad Center</option> <option value="Other">Other</option> </select><br><br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">Visit Other Places besides home and work:</p> <input type="text" id="visitedOtherPlaces" required placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Are you involved in any of these activities in the last 7 days? <b style="font-size:14px;color:red">:</b></p> <select id="Activities" style="font-size:110%;font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> <option value="Online">NA</option> <option value="Online">Online selling</option> <option value="Delivery">Delivery Service</option> <option value="OutRight">Outright Selling</option> <option value="PublicTrans">Public transpo Service</option> <option value="Frontliner">Frontliner </option> <option value="Barangay">Barangay Volunteer</option> <option value="Other">Other</option> </select><br><br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify;color:black;margin-top:0px">Other high risk activity exposure:</p> <input type="text" id="highRiskActivity" required placeholder="Your Answer" style="font-size:110%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br><br> </div> <div class="content"> <p style="padding:20px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left"> <input type="checkbox" name="termsChkbx" id="termsChkbx" onchange="isChecked(this,'saveForm')"> <label for="termsChkbx"> HEREBY CONFIRM THAT ALL STATEMENTS ARE TRUE AND COMPLETE.</label> <br><br> "By signing this form/document, I hereby acknowledge that Autohub Group of Companies, including its parent company, affiliates, subsidiaries, and related companies, as well as their respective officers, directors, shareholders, employees, agents, and other parties with which they do business (hereinafter collectively referred to as “Company”), may use and process all personal information that I have voluntarily and knowingly provided , including those that may be sensitive or confidential as may be disclosed by me, in any transaction or activity related to the Company for the purpose herein stated specifically for public health and safety purposes in effecting control of the COVID-19 infection. Use and processing of Personal Information includes collection, recording, listing, systematization, accumulation, storage, updating, extraction, transfer, anonymization, blocking, deletion, destruction, whether through electronic means or otherwise. I understand that by personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information. <br><br> I hereby release and forever discharge the Company, including its parent company, affiliates, subsidiaries, and related companies, as well as their respective officers, directors, shareholders, employees, agents, and other parties with which they do business, in their official corporate capacities as well as in their individual personal capacities, from any and all sums of money, or any other obligations, privilege, emolument, entitlement, and benefit arising from any and all incident, directly or indirectly related to, the use and processing of all personal and sensitive information. I likewise categorically declare that I do not have and will not institute any claim or cause of action in relation to the use and processing of personal and sensitive information by the Company." <input type="submit" id="saveForm" disabled value="SUBMIT" style="font-size:22px;padding:20px; width:80%;margin:10%;margin-bottom:20px"> </p> </div> </div> </div> </div> <script type = "text/javascript"> function isChecked(chk,saveForm) { var myLayer = document.getElementById(saveForm); if (chk.checked == true) { myLayer.disabled = false; } else { myLayer.disabled = true; }; } </script> <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script> <div id="wait" style="display:none;width:69px;height:89px;border:0px solid red;position:absolute;top:50%;left:50%;padding:2px;"> <img src='images/demo_wait.gif' width="64" height="64" /><br>Loading..</div> <!-- add jquery --> <script type="text/javascript" src="http://code.jquery.com/jquery-1.9.1.js"></script> <script type="text/javascript"> $(document).ready(function(){ //loading gif animator during query or page load $(document).ajaxStart(function(){ $("#wait").css("display", "block"); }); $(document).ajaxComplete(function(){ $("#wait").css("display", "none"); }); //START OF FUNCTION================= SAVING NEW RECORD $("#saveForm").click(function(){ var closeContact =$("input[name='closeContact']:checked").val(); var liveSameHome =$("input[name='liveSameHome']:checked").val(); var lastDateOfContact = $("#lastDateOfContact").val(); var travel = $("input[name='travel']:checked").val(); var travelLocation = $("#travelLocation").val(); var travelDate = $("#travelDate").val(); var symptoms = $("input[name='symptoms']:checked").val(); var symptomsDate = $("#symptomsDate").val(); var visitedPlaces = $("#visitedPlaces").val(); var visitedOtherPlaces = $("#visitedOtherPlaces").val(); var Activities = $("#Activities").val(); var highRiskActivity = $("#highRiskActivity").val(); var hospital = $("input[name='hospital']:checked").val(); var noLiveInsideYes = $("input[name='noLiveInsideYes']:checked").val(); var brgy = $("#brgy").val(); var town = $("#town").val(); var province = $("#province").val(); var city = $("#city").val(); var distance = $("#distance").val(); var dealership = $("#dealership").val(); var empLastName = $("#empLastName").val(); var empFirstName = $("#empFirstName").val(); var empPosition = $("#empPosition").val(); var empDept = $("#empDept").val(); var toDate= $("#toDate").val(); var workSched= $("#workSched").val(); var myTemp= $("#myTemp").val(); var myLoc = $("#myLoc").val(); var hospitalPurpose= $("#hospitalPurpose").val(); var relationshipWithContact= $("#relationshipWithContact").val(); //alert('its working'); //return false; if (workSched == "") { $('#workSched').focus(); $('#workSched').css({'border':'1px solid red'}); $('#workSched').css({'color':'red'}); $('#workSched').attr("placeholder","This is a required field*"); return false; } if (myTemp == "") { $('#myTemp').focus(); $('#myTemp').css({'border':'1px solid red'}); $('#myTemp').css({'color':'red'}); $('#myTemp').attr("placeholder","This is a required field"); return false; } if (empDept == "") { $('#empDept').focus(); $('#empDept').css({'border':'1px solid red'}); $('#empDept').css({'color':'red'}); $('#empDept').attr("placeholder","This is a required field"); return false; } if (empPosition == "") { $('#empPosition').focus(); $('#empPosition').css({'border':'1px solid red'}); $('#empPosition').css({'color':'red'}); $('#empPosition').attr("placeholder","This is a required field"); return false; } if (empLastName == "") { $('#empLastName').focus(); $('#empLastName').css({'border':'1px solid red'}); $('#empLastName').css({'color':'red'}); $('#empLastName').attr("placeholder","This is a required field"); return false; } if (empFirstName == "") { $('#empFirstName').focus(); $('#empFirstName').css({'border':'1px solid red'}); $('#empFirstName').css({'color':'red'}); $('#empFirstName').attr("placeholder","This is a required field"); return false; } if (dealership == "") { $('#dealership').focus(); $('#dealership').css({'border':'1px solid red'}); $('#dealership').css({'color':'red'}); $('#dealership').attr("placeholder","This is a required field**"); return false; } $.ajax({ url: "ahg_saveContactTracingForm_employee.php", type: "POST", async: false, data: { "done": 1, "myLoc" : myLoc, "hospitalPurpose":hospitalPurpose, "closeContact": closeContact, "liveSameHome": liveSameHome, "lastDateOfContact": lastDateOfContact, "travel": travel, "travelLocation": travelLocation, "travelDate": travelDate, "symptoms": symptoms, "symptomsDate": symptomsDate, "visitedPlaces": visitedPlaces, "visitedOtherPlaces": visitedOtherPlaces, "Activities": Activities, "highRiskActivity": highRiskActivity, "hospital": hospital, "noLiveInsideYes": noLiveInsideYes, "brgy": brgy, "town": town, "province": province, "city": city, "distance": distance, "dealership": dealership, "empLastName": empLastName, "empFirstName": empFirstName, "empPosition": empPosition, "empDept": empDept, "workSched": workSched, "myTemp": myTemp, "toDate": toDate }, success: function(data){ //location.href = "ThankYou.html"; window.location='ThankYouPo.php' } }) }); //END OF FUNCTION================= }); </script> </body> </html>

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