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<?php ob_start(); include 'core/init.php'; $toDate = date_create() ->format("m/d/Y"); $myCurTime=$currentTime; ?> <!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{ padding:25px; padding-top:20px; padding-bottom:30px; border:1px solid #fee492 ; width:91%; 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{ 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; } .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="mini.jpg"></img> </div> <div class="divB"> <p style="text-align:center;font-family:Arial;font-size:200%;font-weight:normal">MINI Contact Tracing and Health Declaration Form.</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: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 customers are required to complete this form prior to entering the MINI 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="text" id="toDate" value="<?php echo $toDate;?>" placeholder="Person to visit" 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">Temperature <b style="font-size:14px;color:red"></b></p> <input type="text" id="myTemp" value="" placeholder="Your 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">Person to Visit <b style="font-size:14px;color:red"></b></p> <input type="text" id="empToVisit" required placeholder="Person to visit" style="font-size:120%;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">Customer's Last name <b style="font-size:14px;color:red"></b></p> <input type="text" id="custLastName" required placeholder="Your Answer" style="font-size:120%;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">Customer's First name <b style="font-size:14px;color:red"></b></p> <input type="text" id="custFirstName" required placeholder="Your Answer" style="font-size:120%;font-size:120%;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">Customer's complete address <b style="font-size:14px;color:red"></b></p> <input type="text" id="custAddress" required placeholder="Your Answer" style="font-size:120%;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">Mobile No. <b style="font-size:14px;color:red"></b></p> <input type="text" id="custContact" required placeholder="Your Answer" style="font-size:120%;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">Do you have a history of travel within 14 days?<b style="font-size:14px;color:red"></b></p> <label for="noTravel" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="noTravel" name="travelHistory" value="no"> No </label><br><br> <label for="withTravel" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="withTravel" name="travelHistory" value="yes"> Yes </label><br> <br><br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">If yes, when and where?</p> <input type="text" id="travelInfo" required placeholder="Your Answer" style="font-size:120%;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">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="noRespiratoryIssue" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="noRespiratoryIssue" name="noRespi" value="no"> No </label><br><br> <label for="yesRespiratoryIssue" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="yesRespiratoryIssue" name="noRespi" value="yes"> Yes </label><br> <br><br> <!--<p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Have you experienced any fever or chills prior to your visit to our facility?<b style="font-size:14px;color:red"></b></p> <label for="noChill" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="noChill" name="noChill" value="no"> No </label><br><br> <label for="yesChill" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="yesChill" name="noChill" value="yes"> Yes </label> <br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">If yes, please specify the maximum temperature. </p> <input type="text" id="chillTemp" required placeholder="Your Answer" style="font-size:120%;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:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Do you have any contact or exposed to someone who has suspected / probable / positive case of covid-19?<b style="font-size:14px;color:red"></b></p> <label for="noCovidContact" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="noCovidContact" name="noCovidContact" value="no"> No </label><br><br> <label for="yesCovidContact" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="yesCovidContact" name="noCovidContact" value="yes"> Yes </label><br> <br> <p style="padding:0px;font-family:Arial;font-size:120%;font-weight:normal;text-align:;left;color:black;margin-top:0px">If yes, when is the last date of contact/exposure?</p> <input type="date" id="covidContactDate" required placeholder="Your Answer" style="font-size:120%;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:120%;font-weight:normal;text-align:left;color:black;margin-top:0px">Do you or anyone in the household have any of the above mentioned signs or symptoms or pending covid-19 test results?<b style="font-size:14px;color:red"></b></p> <label for="NohouseHold" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="NohouseHold" name="noHouseHold" value="no"> No </label><br><br> <label for="noHouseHold" style="font-family:Arial;font-size:120%;font-weight:normal;"> <input type="radio" id="YeshouseHold" name="noHouseHold" value="yes"> Yes </label><br> <br> </div> <div class="content"> <p style="padding:20px;font-family:Arial;font-size:120%;font-weight:normal;text-align:justify"> <input type="checkbox" name="checkbox" id="chkConfirm"> <label for="chkConfirm"> HEREBY CONFIRM THAT ALL STATEMENTS ARE TRUE AND COMPLETE.</label> <br><br> "By signing this form/document, I hereby acknowledge that British United Automobiles Inc., 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. 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. <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" value="SUBMIT" style="font-size:22px;padding:20px; width:80%;margin:10%;margin-bottom:20px"> </p> </div> </div> </div> </div> <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(){ var chkConfirm = $("#chkConfirm").val(); var covidContactDate = $("#covidContactDate").val(); var YeshouseHold = $("input[name='noHouseHold']:checked").val(); var NohouseHold = $("input[name='noHouseHold']:checked").val(); var yesCovidContact = $("input[name='noCovidContact']:checked").val(); var noCovidContact = $("input[name='noCovidContact']:checked").val(); var myTemp = $("#myTemp").val(); var yesChill = "na"; var noChill = "na";//$("input[name='noChill']:checked").val(); var yesRespiratoryIssue = $("input[name='noRespi']:checked").val(); var noRespiratoryIssue = $("input[name='noRespi']:checked").val(); var travelInfo = $("#travelInfo").val(); var withTravel = $("input[name='travelHistory']:checked").val(); var noTravel = $("input[name='travelHistory']:checked").val(); var custContact = $("#custContact").val(); var custAddress = $("#custAddress").val(); var custFirstName = $("#custFirstName").val(); var custLastName = $("#custLastName").val(); var empToVisit = $("#empToVisit").val(); var toDate= $("#toDate").val(); 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 (empToVisit == "") { $('#empToVisit').focus(); $('#empToVisit').css({'border':'1px solid red'}); $('#empToVisit').css({'color':'red'}); $('#empToVisit').attr("placeholder","This is a required field"); return false; } if (custLastName == "") { $('#custLastName').focus(); $('#custLastName').css({'border':'1px solid red'}); $('#custLastName').css({'color':'red'}); $('#custLastName').attr("placeholder","This is a required field"); return false; } if (custFirstName == "") { $('#custFirstName').focus(); $('#custFirstName').css({'border':'1px solid red'}); $('#custFirstName').css({'color':'red'}); $('#custFirstName').attr("placeholder","This is a required field"); return false; } if (custAddress == "") { $('#custAddress').focus(); $('#custAddress').css({'border':'1px solid red'}); $('#custAddress').css({'color':'red'}); $('#custAddress').attr("placeholder","This is a required field"); return false; } if (custContact == "") { $('#custContact').focus(); $('#custContact').css({'border':'1px solid red'}); $('#custContact').css({'color':'red'}); $('#custContact').attr("placeholder","This is a required field*"); return false; } $.ajax({ url: "saveContactTracingForm.php", type: "POST", async: false, data: { "done": 1, "chkConfirm": chkConfirm, "YeshouseHold": YeshouseHold, "NohouseHold": NohouseHold, "covidContactDate": covidContactDate, "yesCovidContact": yesCovidContact, "noCovidContact": noCovidContact, "yesChill": yesChill, "noChill": noChill, "yesRespiratoryIssue": yesRespiratoryIssue, "noRespiratoryIssue": noRespiratoryIssue, "travelInfo": travelInfo, "withTravel": withTravel, "noTravel": noTravel, "custContact": custContact, "custAddress": custAddress, "custFirstName": custFirstName, "custLastName": custLastName, "empToVisit": empToVisit, "myTemp": myTemp, "toDate": toDate }, success: function(data){ //location.href = "ThankYou.html"; window.location='ThankYou.html' } }) }); //END OF FUNCTION================= }); function displayFromDatabase(){ var searchString = $("#searchString").val(); $.ajax({ url: "search_load_found_customer.php", type: "POST", async: false, data: { "searchString": searchString, "display": 1 }, success: function(d){ $("#display_area").html(d); } }); } </script> </body> </html>

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