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<?php
$oForm = new plugin_sc_form($this->oBase);
$oForm2 = new plugin_sc_form($this->oBase_ddeur);
$oForm->setMessage($this->tMessage);
?>
<section class="content-header">
<h1 style="display:inline;">
Nouveau dossier
</h1>
</section>
<section class="content" style="margin-top:50px;">
<form class="form-horizontal" method="POST" >
<div class="row">
<div class="col-sm-3">
</div>
<div class="col-sm-4">
<div class="form-group">
<label class="col-sm-7 control-label">Fin du délai de 2 ans</label>
</div>
</div>
<div class="col-sm-5"></div>
</div>
<div class="row">
<div class="col-sm-3">
<div class="form-group">
<label class="col-sm-6 control-label"><?php echo tr('field.date_du_deces')?></label>
<div class="col-sm-6"><?php echo $oForm->getInputText('date_du_deces',array('class'=>'form-control text-center')) ?></div>
</div>
</div>
<div class="col-sm-3">
<input type="text" name="fin2ans" value="<?php ?>" class="text-center form-control"/>
</div>
<div class="col-sm-6">
<div class="form-group">
<label class="col-sm-8 control-label">Pièces complémentaires réclamées le</label>
<div class="col-sm-4"><?php echo $oForm->getInputText('date_de_demande_de_pieces_complementaires',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="form-group">
<label class="col-sm-3 control-label">1ère réception le</label>
<div class="col-sm-3"><?php echo $oForm->getInputText('date_de_reception',array('class'=>'form-control')) ?></div>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<label class="col-sm-8 control-label">Relance faite le</label>
<div class="col-sm-4"><?php echo $oForm->getInputText('date_de_relance',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="form-group">
<label class="col-sm-3 control-label">Demande faite le</label>
<div class="col-sm-3"><?php echo $oForm->getInputText('date_de_la_demande',array('class'=>'form-control')) ?></div>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<label class="col-sm-8 control-label">Relance prévue le</label>
<div class="col-sm-4"><?php echo $oForm->getInputText('date_de_relance_prevue',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
</div>
<div class="col-sm-6">
<div class="form-group">
<label class="col-sm-8 control-label">Paiement prévu le</label>
<div class="col-sm-4"><?php echo $oForm->getInputText('date_Paiement_Prevu_Le',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<div class="form-group">
<label class="col-sm-6 control-label"><?php echo tr('field.droits_ouverts')?></label>
<div class="col-sm-6"><?php echo $oForm->getInputCheckbox('droits_ouverts','1') ?></div>
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<div class="form-group">
<label class="col-sm-6 control-label">1er Refus (DNO) notifié le</label>
<div class="col-sm-6"><?php echo $oForm->getInputText('date_1er_Refus',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="col-sm-5">
<div class="form-group">
<label class="col-sm-7 control-label">Dossier complet reçu le</label>
<div class="col-sm-5"><?php echo $oForm->getInputText('date_arrivee_dossier_complet',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-5">
<div class="form-group">
<label class="col-sm-4 control-label"><?php echo tr('field.nir')?></label>
<div class="col-sm-7"><?php echo $oForm->getInputText('nir',array('class'=>'form-control text-center')) ?></div>
</div>
</div>
<div class="col-sm-7">
<div class="form-group">
<label class="col-sm-4 control-label">Nom de l'assuré DCD</label>
<div class="col-sm-7"><?php echo $oForm->getInputText('nom_de_assure_DCD',array('class'=>'form-control text-center')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="container well">
<h4><u>Demandeurs</u></h4>
<form class="form-horizontal">
<div class="form-group">
<div class="col-sm-4">
<label for="date_de_reception_S3180">S3180 reçu le</label>
<?php echo $oForm2->getInputDate('date_de_reception_formulaire',array('class'=>'form-control text-center','id'=>'date_de_reception_form')) ?>
</div>
<div class="col-sm-4">
<label for="nom">Nom</label>
<?php echo $oForm2->getInputText('nom_form',array('class'=>'form-control','placeholder'=>'Nom','id'=>'nom_form')) ?>
</div>
<div class="col-sm-4">
<label for="prenom">Prénom</label>
<?php echo $oForm2->getInputText('prenom_form',array('class'=>'form-control','placeholder'=>'Prénom','id'=>'prenom_form')) ?>
</div>
</div>
<div class="form-group">
<div class="col-sm-4">
<label for="prenom">Qualité du bénéficiaire</label>
<?php echo utf8_encode($oForm2->getSelect('qualite_form',$this->tJoinmodel_qualiteDdeur,array('class'=>'form-control','id'=>'qualite_form'))) ?>
</div>
<div class="col-sm-4">
<label for="prenom">Décision</label>
<?php echo utf8_encode($oForm2->getSelect('decision_form',$this->tJoinmodel_decisionCaisse,array('class'=>'form-control','id'=>'decision_form'))) ?>
</div>
<div class="col-sm-4">
<label for="prenom">Le</label>
<?php echo $oForm2->getInputDate('date_de_decision_form',array('class'=>'form-control','id'=>'date_de_decision_form')) ?>
</div>
</div>
<div class="form-group">
<div class="col-sm-4">
<button type="button" class="btn btn-default" onclick="myFunction()">Nouveau</button>
</div>
</div>
</form>
<table id="myTable" class="table table-bordered table-striped">
<thead>
<tr>
<th></th>
<th class="text-center">S3180 reçu le</th>
<th class="text-center">Nom</th>
<th class="text-center">Prenom</th>
<th class="text-center">Qualité</th>
<th class="text-center">Décision</th>
<th class="text-center">Le</th>
</tr>
</thead>
<tbody>
</tbody>
</table>
</div>
</div>
<div class="row">
<div class="col-sm-5">
<div class="form-group">
<label class="col-sm-7 control-label"><?php echo tr('field.nombre_de_parts_payees')?></label>
<div class="col-sm-5"><?php echo $oForm->getInputText('nombre_de_parts_payees',array('class'=>'form-control')) ?></div>
</div>
</div>
<div class="col-sm-7">
<div class="form-group">
<label class="col-sm-7 control-label">Montant de la part payé</label>
<div class="col-sm-5"><?php echo $oForm->getInputText('montantDeLaPartPayee',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-5">
<div class="form-group">
<label class="col-sm-7 control-label"><?php echo tr('field.nombre_de_parts_a_payer')?></label>
<div class="col-sm-5"><?php echo $oForm->getInputText('nombre_de_parts_a_payer',array('class'=>'form-control')) ?></div>
</div>
</div>
<div class="col-sm-7">
<div class="form-group">
<label class="col-sm-7 control-label"><?php echo tr('field.montantTotalKDC')?></label>
<div class="col-sm-5"><?php echo $oForm->getInputText('montantTotalKDC',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-5">
<div class="form-group">
<label class="col-sm-7 control-label"><?php echo tr('field.date_de_paiment')?></label>
<div class="col-sm-5"><?php echo $oForm->getInputText('date_de_paiment',array('class'=>'form-control')) ?></div>
</div>
</div>
<div class="col-sm-7">
<label class="col-sm-7 control-label">Montant des parts restantes</label>
<div class="col-sm-5"></div>
</div>
</div>
<div class="row">
<div class="col-sm-5">
<label class="col-sm-7 control-label"><?php echo tr('field.date_regul_2ans')?></label>
<div class="col-sm-5"><?php echo $oForm->getInputText('date_regul_2ans',array('class'=>'form-control')) ?></div>
</div>
<div class="col-sm-7">
<div class="form-group">
<label class="col-sm-7 control-label"><?php echo tr('field.nouveau_montant_part')?></label>
<div class="col-sm-5"><?php echo $oForm->getInputText('nouveau_montant_part',array('class'=>'form-control')) ?></div>
</div>
</div>
</div>
<div class="row">
<div class="form-group">
<label class="col-sm-2 control-label"><?php echo tr('field.observations')?></label>
<div class="col-sm-10"><?php echo $oForm->getInputTextarea('observations',array('class'=>'form-control')) ?></div>
</div>
</div>
<!--<div class="form-group">
<label class="col-sm-2 control-label">< ?php echo tr('field.regul_Fin_2ans')?></label>
<div class="col-sm-10">< ?php echo $oForm->getInputText('regul_Fin_2ans',array('class'=>'form-control')) ?></div>
</div>-->
<?php echo $oForm->getToken('token', $this->token) ?>
<?php echo $oForm2->getToken('token', $this->token) ?>
<div class="form-group">
<div class="col-sm-offset-2 col-sm-10">
<input type="submit" class="btn btn-success" value="<?php echo tr('Ajouter') ?>" />
<a class="btn btn-link" href="<?php echo $this->getLink('global_base::list') ?>"><?php echo tr('annuler') ?></a>
</div>
</div>
</form>
</section> |
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