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Mini Shell

Mini Shell

Direktori : /home/ugotscom/public_html/dg/application/modules/emp/views/
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Current File : /home/ugotscom/public_html/dg/application/modules/emp/views/add.php

<style>
    .form-group{
        padding-right: 27px;
    }
    .dateclass{
        width: 213px;
    }
</style>

<div class="content-wrapper">
     <section class="content-header">
          <h1>Add a New Candidate</h1>
     </section>

     <section class="content">
          <div class="container">
          <div class="row">
        
       <div class="col-md-12">
         <form action="<?php echo site_url('emp/save');?>" method="post">



          <div class="form-group dateclass">
              <label for="Enquiry_source">Enquiry Source:</label>
                         <select name="enquiry_source" class="form-control" placeholder="enquiry_source" required>
                            <?php foreach ($category->result() as $row) :?>
                              <option value="<?php echo $row->enquiry_id;?>"><?php echo $row->source;?></option>
                            <?php endforeach;?>
                         </select>
                     </div>
           
            <h2>Basic Details</h2>
            <div class="form-row">
            <div class="form-group">
             <label for="customer_name">Candidate name:</label>
             <input name="customer_name" type="text" id="customer_name" class="form-control" placeholder="">
           </div>
            <div class="form-group">
             <label for="mobile_no">Candidate Mobile No:</label>
             <input name="mobile_no" type="text" id="mobile_no" class="form-control" placeholder="">
           </div>
     </div>
     <div class="form-row">
           <div class="form-group">
             <label for="email">Email:</label>
             <input name="email" type="text" id="email" class="form-control" placeholder="">
           </div>
             <div class="form-group">
             <label for="landline_no">Date of Birth:</label>
             <input name="dob" type="date" id="dob" class="form-control" placeholder="">
           </div>
           </div>

            <!-- <div class="form-group">
              <label for="location">Locations:</label>
                         <select name="location" class="form-control" placeholder="" required>
                            <?php foreach ($locations->result() as $row) :?>
                              <option value="<?php echo $row->location_id;?>"><?php echo $row->location;?></option>
                            <?php endforeach;?>
                         </select>
                     </div>-->
                       <div class="form-row">
                    <div class="form-group">
             <label for="passport_no">Indos No/Passport no:</label>
             <input name="passport_no" type="text" id="passport_no" class="form-control" placeholder="">
           </div>     
                   <div class="form-group">
             <label for="passport_validity">Passport Validity Till:</label>
             <input name="passport_validity" type="date" id="passport_validity" class="form-control" placeholder="">
           </div>     
      
</div>
             <div class="form-row">
                          <div class="form-group">
             <label for="gender">Gender:</label>
             <div class="form-check form-check-inline">
  <input class="form-check-input" name="gender" type="radio" id="gender" value="male">
  <label class="form-check-label" for="gender">male</label>
</div>
           <div class="form-check form-check-inline">
  <input class="form-check-input" name="gender" type="radio" id="gender" value="female">
  <label class="form-check-label" for="gender">female</label>
</div>

           </div> 
           </div>
             <div class="form-row">
            <div class="form-group">
             <label for="address">Address:</label>
             <input name="address" type="text" id="address" class="form-control" placeholder="">
           </div>  
           </div>
           <h2>Ship Details</h2>
             <div class="form-row">
                         <div class="form-group">
             <label for="vessel">Vessel:</label>
             <input name="vessel" type="text" id="vessel" class="form-control" placeholder="">
           </div>     

                            <div class="form-group">
             <label for="rank">Rank:</label>
             <input name="rank" type="text" id="rank" class="form-control" placeholder="">
           </div>  
                  <div class="form-group">
             <label for="type">Type:</label>
<input name="type" type="text" id="type" class="form-control" placeholder="">
         
</div>
                 <div class="form-group">
             <label for="type">identification_notes:</label>
<input name="identification_notes" type="text" id="identification_notes" class="form-control" placeholder="">
         
</div>
</div>
<h2>Medical Info</h2>
         <div class="form-row">

    
        
              <div class="form-group">
             <label for="height">Height:</label>
             <input name="height" type="text" id="height" class="form-control" placeholder="">
           </div>
              <div class="form-group">
             <label for="weight">Weight:</label>
             <input name="weight" type="text" id="weight" class="form-control" placeholder="">
           </div>
                <div class="form-group">
             <label for="bp">BP:</label>
             <input name="bp" type="text" id="bp" class="form-control" placeholder="">
           </div>
                   <div class="form-group">
             <label for="pulse">Pulse:</label>
             <input name="pulse" type="text" id="pulse" class="form-control" placeholder="">
           </div>
           </div>
             <div class="form-row">
                    <div class="form-group">
             <label for="rr">Respiratory Rate:</label>
             <input name="rr" type="text" id="rr" class="form-control" placeholder="">
           </div>
                  <div class="form-group">
             <label for="chest">Chest:</label>
             <input name="chest" type="text" id="chest" class="form-control" placeholder="">
           </div>
                   <div class="form-group">
             <label for="hemoglobin">Hemoglobin:</label>
             <input name="hemoglobin" type="text" id="hemoglobin" class="form-control" placeholder="">
           </div>
                   <div class="form-group">
             <label for="wbc">WBC:</label>
             <input name="wbc" type="text" id="wbc" class="form-control" placeholder="">
           </div>
           </div>
             <div class="form-row">
                   <div class="form-group">
             <label for="sgpt">SGPT:</label>
             <input name="sgpt" type="text" id="sgpt" class="form-control" placeholder="">
           </div>
                   <div class="form-group">
             <label for="esr">ESR:</label>
             <input name="esr" type="text" id="esr" class="form-control" placeholder="">
           </div>
                   <div class="form-group">
             <label for="sugar">Sugar:</label>
             <input name="sugar" type="text" id="sugar" class="form-control" placeholder="">
           </div>
                   <div class="form-group">
             <label for="cholestrol">Cholestrol:</label>
             <input name="cholestrol" type="text" id="cholestrol" class="form-control" placeholder="">
           </div>
           </div>
             <div class="form-row">
                   <div class="form-group">
             <label for="blood_group">Blood Group:</label>
             <select name="blood_group" id="blood_group" class="form-control">
              
                 <option value="A+">A+</option>
                 <option value="A-">A-</option>
                 <option value="B+">B+</option>
                 <option value="B-">B-</option>
                 <option value="O+">O+</option>
                 <option value="O-">O-</option>
                 <option value="AB+">AB+</option>
                 <option value="AB-">AB-</option>
             </select>
           </div>
           <div class="form-group">
             <label for="xray">X-ray:</label>
             <select name="xray" id="xray" class="form-control">
              
                 <option value="Not done" selected>Not Done</option>
                 <option value="Done">Done</option>
               
             </select>
           </div>
              <div class="form-group">
             <label for="ecg">ECG:</label>
             <select name="ecg" id="ecg" class="form-control">
              
                 <option value="Not done" selected>Not Done</option>
                 <option value="Done">Done</option>
               
             </select>
           </div>
           </div>
             <div class="form-row">
                 <div class="form-group">
             <label for="drec">Distance Vision RE (corrected):</label>
             <input name="drec" type="text" id="drec" class="form-control" placeholder="">
           </div>
                 <div class="form-group">
             <label for="dlec">Distance Vision LE (corrected):</label>
             <input name="dlec" type="text" id="dlec" class="form-control" placeholder="">
           </div>
               <div class="form-group">
             <label for="dreuc">Distance Vision RE (uncorrected):</label>
             <input name="dreuc" type="text" id="dreuc" class="form-control" placeholder="">
           </div>
                 <div class="form-group">
             <label for="dleuc">Distance Vision LE (uncorrected):</label>
             <input name="dleuc" type="text" id="dleuc" class="form-control" placeholder="">
           </div>
           </div>
               <div class="form-group dateclass">
             <label for="added_by">Examination Date:</label>
              <input name="added_date" type="date" id="added_date" class="form-control" placeholder="added_date">
           </div>
                <div class="form-group">
             <label for="added_by">added_by:</label>
              <input name="added_by" type="hidden" id="added_by" class="form-control" placeholder="added_by" value="<?php echo $_SESSION['user_id'];?>">
           </div>
    <div class="form-group">
             
              <input name="branch_id" type="hidden" id="branch_id" class="form-control" placeholder="branch_id" value="<?php echo $_SESSION['branch_id'];?>">
           </div>
  <button type="submit" class="btn btn-default">Submit</button>
                                
              </form>
</div>

  </div>
</div>
</section>

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