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<?php ob_start(); include 'core/init.php'; $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; } .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; } .content{ box-shadow: 2px 2px gray; padding:25px; padding-top:20px; padding-bottom:30px; border:0px solid #fee492 ; width:91%; margin-left:2%; margin-bottom:20px; border-radius:5px; background:white; margin-top:20px; } .doubleDiv{ width:45%;padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px;float:left;margin-right:2%; } .contentA{ box-shadow: 2px 2px gray; padding:5px; padding-top:20px; padding-bottom:30px; border:0px solid #fee492 ; width:96%; height:200px; margin-left:2%; 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; } .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: / .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:180px; 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{ box-shadow: 2px 2px gray; padding:5px; padding-top:20px; padding-bottom:30px; border:0px solid #fee492 ; width:96%; margin-left:1%; margin-bottom:20px; border-radius:5px; background:white; margin-top:20px; } .doubleDiv{ width:100%;padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px;float:left;margin-right:2%;margin-top:30px; } .contentA{ box-shadow: 2px 2px gray; padding:5px; padding-top:20px; padding-bottom:30px; border:0px solid #fee492 ; width:96%; height:400px; margin-left:1%; 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%; } </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" style="float:right;width:100%"> <!--<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">SELF DECLARATION AND CONTACT TRACING FORM.<br> <input type="text" id="myLoc" style="border:1px solid white;text-align:center" readonly value="<?php echo $myLoc;?>"></p> </div> <div class="divC" > <!--<img class="imgSRC" src="autohub_logo.png" style="float:right"></img> --> </div> <div class="MainDivBody"> <div class="content"> <p style="padding:20px;font-family:Arial;font-size:100%;font-weight:normal;text-align:justify"> To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our clients and visitors like you, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Information collected will be kept safely and any personal information will not be disclosed unless as required by law. </p> <p style="padding:20px;padding-bottom:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:justify;color:red"> Required</p> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Today's Date: <b style="font-size:14px;color:red"></b></p> <input type="text" id="toDate" disabled value="<?php echo $toDate;?>" placeholder="Person to visit" style="background:transparent;font-size:100%;border:0px solid red;border-bottom:0px solid gray;padding-top:0px;width:50%;font-family:Arial;color:red"> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Visitor's Name <b style="font-size:14px;color:red"></b></p> <input type="text" id="txtVisitorsName" value="" placeholder="Your Answer" style="font-size:100%;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:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">ID Presented: <b style="font-size:14px;color:red"></b></p> <input type="text" id="txtIDPresented" required placeholder="Person to visit" style="font-size:100%;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:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Visitor's Home Address:<b style="font-size:14px;color:red"></b></p> <input type="text" id="txtVisitorsHomeAddress" required placeholder="Your Answer" style="font-size:100%;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:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Business / Office Address: <b style="font-size:14px;color:red"></b></p> <input type="text" id="txtOfficeAddress" required placeholder="Your Answer" style="font-size:100%;font-size:100%;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:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Personal Contact # (Mobile / Home #) <b style="font-size:14px;color:red"></b></p> <input type="text" id="txtPersonalContact" required placeholder="Your Answer" style="font-size:100%;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:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Purpose of Visit. <b style="font-size:14px;color:red"></b></p> <input type="text" id="txtPurpose" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"> </div> <div class="content" style="height:80px"> <p style="width:45%;padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px;float:left;margin-right:2%">Temperature: <b style="font-size:14px;color:red"></b><input type="text" id="txtTempReading" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"></p> <p style="width:45%;padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px;float:left;margin-left:5%">Recorded by: <b style="font-size:14px;color:red"></b><input type="text" id="txtRecordedBy" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"></p> </div> <div class="contentA" style="min-height:200px"> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Do you have any of the following sypmtom(s):? Please check the box if applicable:<b style="font-size:14px;color:red"></b></p> <label for="fever" style="float:left;margin:10px;font-family:Arial;font-size:100%;font-weight:normal;"> <input type="checkbox" id="fever" name="fever"> Dry Cough </label> <label for="dryCough" style="float:left;margin:10px;font-family:Arial;font-size:100%;font-weight:normal;"> <input type="checkbox" id="dryCough" name="dryCough"> Dry Cough </label> <label for="shortBreath" style="float:left;margin:10px;font-family:Arial;font-size:100%;font-weight:normal;"> <input type="checkbox" id="shortBreath" name="shortBreath"> Shortness of breath </label> <label for="SoreThroat" style="float:left;margin:10px;font-family:Arial;font-size:100%;font-weight:normal;"> <input type="checkbox" id="SoreThroat" name="SoreThroat"> Sore Throat </label> <label for="Headache" style="float:left;margin:10px;font-family:Arial;font-size:100%;font-weight:normal;"> <input type="checkbox" id="Headache" name="Headache"> Headache </label> <br><br><br> <p class="doubleDiv">Since When?: <b style="font-size:14px;color:red"></b><input type="text" id="txtSinceWhen" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"></p> <p class="doubleDiv">Others: <b style="font-size:14px;color:red"></b><input type="text" id="txtOthers" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"></p> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Have you been in contact with a confirmed COVID-19 patient in the past 21 days?<b style="font-size:14px;color:red"></b></p> <label for="noContact" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="noContact" name="noContact" value="no"> No </label><br><br> <label for="yesContact" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="yesContact" name="noContact" value="yes"> Yes </label><br> <br><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Have you been in the hospital or health care facility in the past 21 days?<b style="font-size:14px;color:red"></b></p> <label for="noHospital" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="noHospital" name="noHospital" value="no"> No </label><br><br> <label for="yesHospital" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="yesHospital" name="noHospital" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:;left;color:black;margin-top:0px">If yes, state your purpose?</p> <input type="text" id="txtHospitalPurpose" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:50%"><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Do you live inside a declared COVID 19 locked down area?<b style="font-size:14px;color:red"></b></p> <label for="noLockDown" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="noLockDown" name="noLockDown" value="no"> No </label><br><br> <label for="yesLockDown" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="yesLockDown" name="noLockDown" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:;left;color:black;margin-top:0px">If yes, please indicate the affected countries/regions/municipalities and Barangay:</p> <input type="text" id="txtLockDownArea" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br> </div> <div class="content"> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:left;color:black;margin-top:0px">Did you travel local or International in the past 21 days?<b style="font-size:14px;color:red"></b></p> <label for="noTravel" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="noTravel" name="noTravel" value="no"> No </label><br><br> <label for="yesLockDown" style="font-family:Arial;font-size:100%;font-weight:normal;"> <input type="radio" id="yesTravel" name="noTravel" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:100%;font-weight:normal;text-align:;left;color:black;margin-top:0px">If yes please state the country, region and City:</p> <input type="text" id="txtTravelledCity" required placeholder="Your Answer" style="font-size:100%;border:0px solid red;border-bottom:1px solid gray;padding-top:10px;width:100%"><br> </div> <div class="content"> <p style="padding:20px;font-family:Arial;font-size:100%;font-weight:normal;text-align:justify"> <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. 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" disabled id="saveForm" 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='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(){ //toDate txtVisitorsName txtIDPresented txtVisitorsHomeAddress txtOfficeAddress txtPersonalContact txtPurpose txtTempReading txtRecordedBy fever dryCough shortBreath SoreThroat Headache txtSinceWhen txtOthers noContact yesContact noHospital yesHospital txtHospitalPurpose noLockDown txtLockDownArea noTravel yesTravel txtTravelledCity var toDate = $("#toDate").val(); var txtVisitorsName = $("#txtVisitorsName").val(); var txtIDPresented = $("#txtIDPresented").val(); var txtVisitorsHomeAddress = $("#txtVisitorsHomeAddress").val(); var txtOfficeAddress = $("#txtOfficeAddress").val(); var txtPersonalContact = $("#txtPersonalContact").val(); var txtPurpose = $("#txtPurpose").val(); var txtTempReading = $("#txtTempReading").val(); var txtRecordedBy = $("#txtRecordedBy").val(); var fever = $('#fever').is(':checked'); //var fever = $("#fever").val(); var dryCough =$('#dryCough').is(':checked'); var shortBreath =$('#shortBreath').is(':checked'); var SoreThroat =$('#SoreThroat').is(':checked'); var Headache =$('#Headache').is(':checked'); var txtSinceWhen = $("#txtSinceWhen").val(); var txtOthers = $("#txtOthers").val(); var myLoc = $("#myLoc").val(); var txtHospitalPurpose = $("#txtHospitalPurpose").val(); var txtLockDownArea = $("#txtLockDownArea").val(); var txtTravelledCity = $("#txtTravelledCity").val(); var noLockDown = $("input[name='noLockDown']:checked").val(); var yesLockDown = $("input[name='noLockDown']:checked").val(); var noContact = $("input[name='noContact']:checked").val(); var yesContact = $("input[name='noContact']:checked").val(); var noHospital = $("input[name='noHospital']:checked").val(); var yesHospital = $("input[name='noHospital']:checked").val(); var yesTravel = $("input[name='noTravel']:checked").val(); var noTravel = $("input[name='noTravel']:checked").val(); if (txtVisitorsName == "") { $('#txtVisitorsName').focus(); $('#txtVisitorsName').css({'border':'1px solid red'}); $('#txtVisitorsName').css({'color':'red'}); $('#txtVisitorsName').attr("placeholder","This is a required field"); return false; } if (txtPersonalContact == "") { $('#txtPersonalContact').focus(); $('#txtPersonalContact').css({'border':'1px solid red'}); $('#txtPersonalContact').css({'color':'red'}); $('#txtPersonalContact').attr("placeholder","This is a required field"); return false; } if (txtPurpose == "") { $('#txtPurpose').focus(); $('#txtPurpose').css({'border':'1px solid red'}); $('#txtPurpose').css({'color':'red'}); $('#txtPurpose').attr("placeholder","This is a required field"); return false; } if (txtVisitorsHomeAddress == "") { $('#txtVisitorsHomeAddress').focus(); $('#txtVisitorsHomeAddress').css({'border':'1px solid red'}); $('#txtVisitorsHomeAddress').css({'color':'red'}); $('#txtVisitorsHomeAddress').attr("placeholder","This is a required field"); return false; } if (txtOfficeAddress == "") { $('#txtOfficeAddress').focus(); $('#txtOfficeAddress').css({'border':'1px solid red'}); $('#txtOfficeAddress').css({'color':'red'}); $('#txtOfficeAddress').attr("placeholder","This is a required field**"); return false; } $.ajax({ url: "ahg_guest_saveContactTracingForm.php", type: "POST", async: false, data: { "done": 1, "myLoc" : myLoc, "txtVisitorsName" : txtVisitorsName, "txtIDPresented" : txtIDPresented, "txtVisitorsHomeAddress" : txtVisitorsHomeAddress, "txtOfficeAddress" : txtOfficeAddress, "txtPersonalContact" : txtPersonalContact, "txtPurpose" : txtPurpose, "txtTempReading" : txtTempReading, "txtRecordedBy" : txtRecordedBy, "fever" : fever, "dryCough" : dryCough, "shortBreath" : shortBreath, "SoreThroat" : SoreThroat, "Headache" : Headache, "txtSinceWhen" : txtSinceWhen, "txtOthers" : txtOthers, "txtHospitalPurpose" : txtHospitalPurpose, "txtLockDownArea" : txtLockDownArea, "txtTravelledCity" : txtTravelledCity, "noLockDown" : noLockDown, "yesLockDown" : yesLockDown, "noContact" : noContact, "yesContact" : yesContact, "noHospital" : noHospital, "yesHospital" : yesHospital, "yesTravel" : yesTravel, "noTravel" : noTravel, "toDate" : toDate }, success: function(data){ //location.href = "ThankYou.html"; window.location='ThankYouPo.php'; } }) }); //END OF FUNCTION================= }); </script> </body> </html>

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