9a8e1d7ab5
- express save captures visit_id; visit-linked submit defers SO creation (saves draft + signature) and returns to the visit for grouping. - portal dashboard 'Start a Visit' tile for sales reps. - fix duplicate-authorizer completion email; visit grouped SOs email once per SO. - define visit._assessment_sale_type (ADP grouping key) - fixes AttributeError. Verified on a westin-v19 clone (load + ADP-grouping + combination-guard smoke test, mail neutralised) then deployed to westin prod 19.0.2.10.0. Co-Authored-By: Claude Opus 4.8 (1M context) <noreply@anthropic.com>
1695 lines
129 KiB
XML
1695 lines
129 KiB
XML
<?xml version="1.0" encoding="utf-8"?>
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<odoo>
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<!-- Express Assessment Form Template -->
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<template id="portal_assessment_express" name="ADP Assessment Express Form">
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<t t-call="portal.portal_layout">
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||
<t t-set="breadcrumbs_searchbar" t-value="False"/>
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||
<t t-set="no_breadcrumbs" t-value="True"/>
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||
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||
<!-- Breadcrumbs -->
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||
<div class="container mt-3">
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||
<nav aria-label="breadcrumb">
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||
<ol class="breadcrumb mb-0">
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||
<li class="breadcrumb-item"><a href="/my/home">Home</a></li>
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||
<li class="breadcrumb-item"><a href="/my/assessments">Assessments</a></li>
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||
<li class="breadcrumb-item active" aria-current="page">
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<t t-if="assessment"><t t-out="assessment.reference"/></t>
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<t t-else="">New Express Assessment</t>
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</li>
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||
</ol>
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</nav>
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||
</div>
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<!-- Compact form styling -->
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<style>
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.assessment-express-form .card {
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margin-bottom: 1rem !important;
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}
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||
.assessment-express-form .card-body {
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padding: 1.25rem !important;
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||
}
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||
.assessment-express-form .card-header {
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||
padding: 0.75rem 1.25rem !important;
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||
}
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||
.assessment-express-form .mb-4 {
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||
margin-bottom: 0.75rem !important;
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||
}
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||
.assessment-express-form .mb-3 {
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margin-bottom: 0.5rem !important;
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||
}
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.assessment-express-form .form-label {
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margin-bottom: 0.25rem !important;
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||
font-size: 0.9rem;
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||
}
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||
.assessment-express-form .form-control,
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||
.assessment-express-form .form-select {
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||
padding: 0.375rem 0.75rem !important;
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||
font-size: 0.95rem;
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||
}
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||
.assessment-express-form .form-select-lg {
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padding: 0.5rem 1rem !important;
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||
font-size: 1rem;
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||
}
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||
.assessment-express-form .form-check {
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||
margin-bottom: 0.25rem !important;
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||
}
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||
.assessment-express-form .row {
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||
margin-bottom: 0 !important;
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||
}
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||
.assessment-express-form h2 {
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font-size: 1.4rem;
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margin-bottom: 1rem !important;
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||
}
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.assessment-express-form h4 {
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||
font-size: 1.1rem;
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margin-bottom: 0 !important;
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||
}
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||
.assessment-express-form .input-group-text {
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||
padding: 0.375rem 0.5rem;
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||
font-size: 0.9rem;
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}
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.assessment-express-form .gap-4 {
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gap: 1rem !important;
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}
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</style>
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<div class="container py-3">
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<!-- Header -->
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<div class="text-center mb-3">
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<h1 class="h3 fw-bold text-primary">ADP Assessment Express Form</h1>
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<p class="text-muted small mb-0" t-if="assessment">Reference: <strong t-esc="assessment.reference"/></p>
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</div>
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<!-- Form -->
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<form method="POST" action="/my/assessment/express/save" class="assessment-express-form" enctype="multipart/form-data">
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<input type="hidden" name="csrf_token" t-att-value="request.csrf_token()"/>
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<input type="hidden" name="assessment_id" t-att-value="assessment.id if assessment else ''"/>
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<input type="hidden" name="current_page" value="1"/>
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<input type="hidden" name="visit_id" id="express_visit_id" t-att-value="visit_id or ''"/>
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<!-- Part of an assessment visit: completing returns to the visit, which groups
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this device with the rest into one funding-routed ADP order. -->
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<div t-if="visit_id" class="alert alert-info d-flex align-items-start gap-2 mb-3">
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<i class="fa fa-clipboard mt-1"/>
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<div>
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<strong>Part of an assessment visit.</strong>
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Completing this device returns you to the visit — it is grouped with the
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visit's other ADP devices into a single sale order when you complete the visit.
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</div>
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</div>
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<!-- Equipment Selection Section -->
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<div class="card shadow-sm">
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<div class="card-body">
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||
<!-- Equipment Type Selection -->
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||
<div class="mb-4">
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<label class="form-label fw-bold">Choose Equipment <span class="text-danger">*</span></label>
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<select name="equipment_type" id="equipment_type" class="form-select form-select-lg" required="required">
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<option value="">-- Select Equipment --</option>
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<option value="rollator" t-att-selected="assessment.equipment_type == 'rollator' if assessment else False">Rollator</option>
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<option value="wheelchair" t-att-selected="assessment.equipment_type == 'wheelchair' if assessment else False">Wheelchair</option>
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<option value="powerchair" t-att-selected="assessment.equipment_type == 'powerchair' if assessment else False">Powerchair</option>
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||
<option value="scooter" t-att-selected="assessment.equipment_type == 'scooter' if assessment else False">Mobility Scooter</option>
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</select>
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</div>
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||
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||
<!-- ============================================ -->
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||
<!-- ROLLATOR FORM -->
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||
<!-- ============================================ -->
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<div id="rollator_form" class="equipment-form" style="display: none;">
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<h2 class="text-center fw-bold text-uppercase mb-4">Rollator Assessment</h2>
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||
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<!-- Rollator Type -->
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<div class="mb-4">
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<label class="form-label fw-bold">Rollator Type</label>
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<select name="rollator_type" class="form-select">
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<option value="">-- Select Type --</option>
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<option value="type_1" t-att-selected="assessment.rollator_type == 'type_1' if assessment else False">Type 1</option>
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<option value="type_2" t-att-selected="assessment.rollator_type == 'type_2' if assessment else False">Type 2</option>
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<option value="type_3" t-att-selected="assessment.rollator_type == 'type_3' if assessment else False">Type 3</option>
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</select>
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</div>
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<!-- Rollator Measurements -->
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||
<div class="row mb-4">
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<div class="col-12 col-md-6">
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<label class="form-label fw-bold">Handle Height</label>
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<div class="input-group">
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<input type="number" step="0.5" name="rollator_handle_height" class="form-control" placeholder="in Inches"
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t-att-value="assessment.rollator_handle_height if assessment else ''"/>
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<span class="input-group-text">Inch</span>
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||
</div>
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</div>
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||
<div class="col-12 col-md-6">
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<label class="form-label fw-bold">Seat Height</label>
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<div class="input-group">
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<input type="number" step="0.5" name="rollator_seat_height" class="form-control" placeholder="in Inches"
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t-att-value="assessment.rollator_seat_height if assessment else ''"/>
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<span class="input-group-text">Inch</span>
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</div>
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</div>
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</div>
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<!-- Rollator Addons -->
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<div class="mb-4">
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<label class="form-label fw-bold">Choose Addons</label>
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<div class="d-flex flex-wrap gap-4">
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<t t-set="rollator_addon_list" t-value="(assessment.rollator_addons or '').split(',') if assessment else []"/>
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<div class="form-check">
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<input type="checkbox" name="rollator_addons" value="Curb Climber" class="form-check-input" id="addon_curb"
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t-att-checked="'Curb Climber' in rollator_addon_list"/>
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<label class="form-check-label" for="addon_curb">Curb Climber</label>
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</div>
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<div class="form-check">
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<input type="checkbox" name="rollator_addons" value="Cane Holder" class="form-check-input" id="addon_cane"
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t-att-checked="'Cane Holder' in rollator_addon_list"/>
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<label class="form-check-label" for="addon_cane">Cane Holder</label>
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</div>
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<div class="form-check">
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<input type="checkbox" name="rollator_addons" value="Cup Holder" class="form-check-input" id="addon_cup"
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t-att-checked="'Cup Holder' in rollator_addon_list"/>
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<label class="form-check-label" for="addon_cup">Cup Holder</label>
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</div>
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<div class="form-check">
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<input type="checkbox" name="rollator_addons" value="Slow Down Brakes" class="form-check-input" id="addon_brakes"
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t-att-checked="'Slow Down Brakes' in rollator_addon_list"/>
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||
<label class="form-check-label" for="addon_brakes">Slow Down Brakes</label>
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||
</div>
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||
<div class="form-check">
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<input type="checkbox" name="rollator_addons" value="Footrest" class="form-check-input" id="addon_footrest"
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t-att-checked="'Footrest' in rollator_addon_list"/>
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<label class="form-check-label" for="addon_footrest">Footrest</label>
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</div>
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</div>
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</div>
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</div>
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<!-- ============================================ -->
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<!-- WHEELCHAIR FORM -->
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||
<!-- ============================================ -->
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<div id="wheelchair_form" class="equipment-form" style="display: none;">
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||
<h2 class="text-center fw-bold text-uppercase mb-4">Wheelchair Assessment</h2>
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||
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||
<!-- Wheelchair Type -->
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||
<div class="mb-4">
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<label class="form-label fw-bold">Wheelchair Type <span class="text-danger">*</span></label>
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<select name="wheelchair_type" class="form-select">
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<option value="">-- Select Type --</option>
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||
<option value="type_1" t-att-selected="assessment.wheelchair_type == 'type_1' if assessment else False">Type 1 - Adult Manual Standard Wheelchair</option>
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||
<option value="type_2" t-att-selected="assessment.wheelchair_type == 'type_2' if assessment else False">Type 2 - Adult Manual Lightweight Wheelchair</option>
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||
<option value="type_3" t-att-selected="assessment.wheelchair_type == 'type_3' if assessment else False">Type 3 - Adult Manual Ultra Lightweight Wheelchair</option>
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||
<option value="type_4" t-att-selected="assessment.wheelchair_type == 'type_4' if assessment else False">Type 4 - Adult Manual Tilt Wheelchair</option>
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<option value="type_5" t-att-selected="assessment.wheelchair_type == 'type_5' if assessment else False">Type 5 - Adult Manual Dynamic Tilt Wheelchair</option>
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</select>
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</div>
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||
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||
<!-- Wheelchair Measurements -->
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||
<div class="row mb-3">
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||
<div class="col-12 col-md-6 mb-3">
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||
<label class="form-label fw-bold">Seat Width (Inches) <span class="text-danger">*</span></label>
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||
<div class="input-group">
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||
<input type="number" step="0.5" name="seat_width" class="form-control" required="required"
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t-att-value="assessment.seat_width if assessment else ''"/>
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<span class="input-group-text">Inch</span>
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</div>
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</div>
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<div class="col-12 col-md-6 mb-3">
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<label class="form-label fw-bold">Seat Depth (Inches) <span class="text-danger">*</span></label>
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||
<div class="input-group">
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||
<input type="number" step="0.5" name="seat_depth" class="form-control" required="required"
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t-att-value="assessment.seat_depth if assessment else ''"/>
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<span class="input-group-text">Inch</span>
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</div>
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</div>
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</div>
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||
<div class="row mb-3">
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||
<div class="col-12 col-md-6 mb-3">
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<label class="form-label fw-bold">Legrest Length (Inches) <span class="text-danger">*</span></label>
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||
<div class="input-group">
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||
<input type="number" step="0.5" name="legrest_length" class="form-control" required="required"
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||
t-att-value="assessment.legrest_length if assessment else ''"/>
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||
<span class="input-group-text">Inch</span>
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||
</div>
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||
</div>
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||
<div class="col-12 col-md-6 mb-3">
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||
<label class="form-label fw-bold">Seat to Floor Height (Inches) <span class="text-danger">*</span></label>
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||
<div class="input-group">
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||
<input type="number" step="0.5" name="seat_to_floor_height" class="form-control" placeholder="Including Cushion" required="required"
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||
t-att-value="assessment.seat_to_floor_height if assessment else ''"/>
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||
<span class="input-group-text">Inch</span>
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||
</div>
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||
</div>
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||
</div>
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||
<div class="row mb-4">
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||
<div class="col-12 col-md-6 mb-3">
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||
<label class="form-label fw-bold">Cane Height (floor to handle) (Inches) <span class="text-danger">*</span></label>
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||
<div class="input-group">
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||
<input type="number" step="0.5" name="cane_height" class="form-control" placeholder="Ground to Canes" required="required"
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||
t-att-value="assessment.cane_height if assessment else ''"/>
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||
<span class="input-group-text">Inch</span>
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||
</div>
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||
</div>
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||
<div class="col-12 col-md-6 mb-3">
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||
<label class="form-label fw-bold">Back Height (Inches) <span class="text-danger">*</span></label>
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||
<div class="input-group">
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||
<input type="number" step="0.5" name="back_height" class="form-control" required="required"
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||
t-att-value="assessment.back_height if assessment else ''"/>
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||
<span class="input-group-text">Inch</span>
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||
</div>
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||
</div>
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||
</div>
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||
|
||
<!-- Frame Options -->
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||
<t t-set="frame_options_list" t-value="(assessment.frame_options or '').split(',') if assessment else []"/>
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||
<div class="mb-4">
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||
<label class="form-label fw-bold">Frame Options – ADP Funded Options (Rationale Required for these options)</label>
|
||
<div class="d-flex flex-wrap gap-4">
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||
<div class="form-check">
|
||
<input type="checkbox" name="frame_options" value="Recliner Option" class="form-check-input" id="frame_recliner"
|
||
t-att-checked="'Recliner Option' in frame_options_list"/>
|
||
<label class="form-check-label" for="frame_recliner">Recliner Option</label>
|
||
</div>
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||
<div class="form-check">
|
||
<input type="checkbox" name="frame_options" value="Dynamic Tilt Frame" class="form-check-input" id="frame_tilt"
|
||
t-att-checked="'Dynamic Tilt Frame' in frame_options_list"/>
|
||
<label class="form-check-label" for="frame_tilt">Dynamic Tilt Frame</label>
|
||
</div>
|
||
<div class="form-check">
|
||
<input type="checkbox" name="frame_options" value="Titanium Frame" class="form-check-input" id="frame_titanium"
|
||
t-att-checked="'Titanium Frame' in frame_options_list"/>
|
||
<label class="form-check-label" for="frame_titanium">Titanium Frame</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Wheel Options -->
|
||
<t t-set="wheel_options_list" t-value="(assessment.wheel_options or '').split(',') if assessment else []"/>
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Wheel Options/Addons – ADP Funded Options</label>
|
||
<div class="row">
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Caster Pin Locks (pair)" class="form-check-input" id="wheel_caster"
|
||
t-att-checked="'Caster Pin Locks (pair)' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_caster">Caster Pin Locks (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Spoke Protectors (pair)" class="form-check-input" id="wheel_spoke"
|
||
t-att-checked="'Spoke Protectors (pair)' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_spoke">Spoke Protectors (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Amputee Axle Plates (pair)" class="form-check-input" id="wheel_amputee"
|
||
t-att-checked="'Amputee Axle Plates (pair)' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_amputee">Amputee Axle Plates (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Quick Release Axles (pair)" class="form-check-input" id="wheel_quick"
|
||
t-att-checked="'Quick Release Axles (pair)' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_quick">Quick Release Axles (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Uni-Lateral Wheel Lock" class="form-check-input" id="wheel_uni"
|
||
t-att-checked="'Uni-Lateral Wheel Lock' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_uni">Uni-Lateral Wheel Lock</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="One Arm/Lever Drive" class="form-check-input" id="wheel_onearm"
|
||
t-att-checked="'One Arm/Lever Drive' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_onearm">One Arm/Lever Drive</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Plastic Coated Handrims" class="form-check-input" id="wheel_plastic"
|
||
t-att-checked="'Plastic Coated Handrims' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_plastic">Plastic Coated Handrims</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Projected Handrims (pair)" class="form-check-input" id="wheel_projected"
|
||
t-att-checked="'Projected Handrims (pair)' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_projected">Projected Handrims (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="wheel_options" value="Grade Aids (pair)" class="form-check-input" id="wheel_grade"
|
||
t-att-checked="'Grade Aids (pair)' in wheel_options_list"/>
|
||
<label class="form-check-label" for="wheel_grade">Grade Aids (pair)</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Legrest Accessories -->
|
||
<t t-set="legrest_options_list" t-value="(assessment.legrest_options or '').split(',') if assessment else []"/>
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Legrest Accessories – ADP Funded Options</label>
|
||
<div class="row">
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="legrest_options" value="Angle Adjustable Footplates" class="form-check-input" id="leg_angle"
|
||
t-att-checked="'Angle Adjustable Footplates' in legrest_options_list"/>
|
||
<label class="form-check-label" for="leg_angle">Angle Adjustable Footplates</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="legrest_options" value="Elevating Legrests (pair)" class="form-check-input" id="leg_elevating"
|
||
t-att-checked="'Elevating Legrests (pair)' in legrest_options_list"/>
|
||
<label class="form-check-label" for="leg_elevating">Elevating Legrests (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="legrest_options" value="Legrest Padding – Foot/Leg Support Options (Modular)" class="form-check-input" id="leg_padding"
|
||
t-att-checked="'Legrest Padding' in legrest_options_list"/>
|
||
<label class="form-check-label" for="leg_padding">Legrest Padding – Foot/Leg Support Options (Modular)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="legrest_options" value="Footrest Padding – Foot/Leg Support Options (Custom)" class="form-check-input" id="leg_footrest_pad"
|
||
t-att-checked="'Footrest Padding' in legrest_options_list"/>
|
||
<label class="form-check-label" for="leg_footrest_pad">Footrest Padding – Foot/Leg Support Options (Custom)</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="legrest_options" value="Calf Panel – Foot/Leg Support (Modular)" class="form-check-input" id="leg_calf"
|
||
t-att-checked="'Calf Panel' in legrest_options_list"/>
|
||
<label class="form-check-label" for="leg_calf">Calf Panel – Foot/Leg Support (Modular)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="legrest_options" value="Calf Panel (Custom) – Foot/Leg Support (Custom)" class="form-check-input" id="leg_calf_custom"
|
||
t-att-checked="'Calf Panel (Custom)' in legrest_options_list"/>
|
||
<label class="form-check-label" for="leg_calf_custom">Calf Panel (Custom) – Foot/Leg Support (Custom)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="legrest_options" value="Flip Forward Calf Panel – Foot/Leg Support (Custom)" class="form-check-input" id="leg_flip"
|
||
t-att-checked="'Flip Forward Calf Panel' in legrest_options_list"/>
|
||
<label class="form-check-label" for="leg_flip">Flip Forward Calf Panel – Foot/Leg Support (Custom)</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Additional ADP Options -->
|
||
<t t-set="additional_options_list" t-value="(assessment.additional_adp_options or '').split(',') if assessment else []"/>
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Additional ADP Funded Options</label>
|
||
<div class="row">
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="additional_adp_options" value="Adjustable Tension Back Upholstery" class="form-check-input" id="add_tension"
|
||
t-att-checked="'Adjustable Tension Back Upholstery' in additional_options_list"/>
|
||
<label class="form-check-label" for="add_tension">Adjustable Tension Back Upholstery</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="additional_adp_options" value="Heavy Duty Cross Braces & Upholstery" class="form-check-input" id="add_heavy"
|
||
t-att-checked="'Heavy Duty Cross Braces' in additional_options_list"/>
|
||
<label class="form-check-label" for="add_heavy">Heavy Duty Cross Braces & Upholstery</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="additional_adp_options" value="Stroller Handles/Paediatric" class="form-check-input" id="add_stroller"
|
||
t-att-checked="'Stroller Handles' in additional_options_list"/>
|
||
<label class="form-check-label" for="add_stroller">Stroller Handles/Paediatric</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="additional_adp_options" value="Oxygen Tank Holder" class="form-check-input" id="add_o2"
|
||
t-att-checked="'Oxygen Tank Holder' in additional_options_list"/>
|
||
<label class="form-check-label" for="add_o2">Oxygen Tank Holder</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="additional_adp_options" value="Ventilator Tray" class="form-check-input" id="add_vent"
|
||
t-att-checked="'Ventilator Tray' in additional_options_list"/>
|
||
<label class="form-check-label" for="add_vent">Ventilator Tray</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Cushion and Backrest -->
|
||
<div class="row mb-4">
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Cushion</label>
|
||
<input type="text" name="cushion_info" class="form-control" placeholder="Enter cushion details..."
|
||
t-att-value="assessment.cushion_info if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Backrest</label>
|
||
<input type="text" name="backrest_info" class="form-control" placeholder="Enter backrest details..."
|
||
t-att-value="assessment.backrest_info if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Seat Belt Type -->
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Seat Belt Type – ADP Funded Options</label>
|
||
<div class="row">
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="standard" class="form-check-input" id="belt_standard"
|
||
t-att-checked="assessment.seatbelt_type == 'standard' if assessment else False"/>
|
||
<label class="form-check-label" for="belt_standard">Standard Belt – No Padding</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="padded" class="form-check-input" id="belt_padded"
|
||
t-att-checked="assessment.seatbelt_type == 'padded' if assessment else False"/>
|
||
<label class="form-check-label" for="belt_padded">Padded Belt – Positioning Belts (Modular)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="4point" class="form-check-input" id="belt_4point"
|
||
t-att-checked="assessment.seatbelt_type == '4point' if assessment else False"/>
|
||
<label class="form-check-label" for="belt_4point">4 Point Seat Belt – Positioning Belts (Modular)</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="chest_harness" class="form-check-input" id="belt_chest"
|
||
t-att-checked="assessment.seatbelt_type == 'chest_harness' if assessment else False"/>
|
||
<label class="form-check-label" for="belt_chest">Chest Harness – Positioning Belts (Modular)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="additional_pads" class="form-check-input" id="belt_pads"
|
||
t-att-checked="assessment.seatbelt_type == 'additional_pads' if assessment else False"/>
|
||
<label class="form-check-label" for="belt_pads">Additional Pads – Positioning Belts (Custom)</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Additional Information -->
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Additional Information/Customization</label>
|
||
<textarea name="additional_customization" class="form-control" rows="4" placeholder="Enter any additional requirements or customization notes..."><t t-esc="assessment.additional_customization if assessment else ''"/></textarea>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- ============================================ -->
|
||
<!-- POWERCHAIR FORM -->
|
||
<!-- ============================================ -->
|
||
<div id="powerchair_form" class="equipment-form" style="display: none;">
|
||
<h2 class="text-center fw-bold text-uppercase mb-4">Powerchair Assessment</h2>
|
||
|
||
<!-- Powerchair Type -->
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Powerchair Type <span class="text-danger">*</span></label>
|
||
<select name="powerchair_type" class="form-select">
|
||
<option value="">-- Select Type --</option>
|
||
<option value="type_1" t-att-selected="assessment.powerchair_type == 'type_1' if assessment else False">Adult Power Base Type 1</option>
|
||
<option value="type_2" t-att-selected="assessment.powerchair_type == 'type_2' if assessment else False">Adult Power Base Type 2</option>
|
||
<option value="type_3" t-att-selected="assessment.powerchair_type == 'type_3' if assessment else False">Adult Power Base Type 3</option>
|
||
</select>
|
||
</div>
|
||
|
||
<!-- Powerchair Measurements -->
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Seat Width (Inches) <span class="text-danger">*</span></label>
|
||
<div class="input-group">
|
||
<input type="number" step="0.5" name="seat_width" class="form-control powerchair-field"
|
||
t-att-value="assessment.seat_width if assessment else ''"/>
|
||
<span class="input-group-text">Inch</span>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Seat Depth (Inches) <span class="text-danger">*</span></label>
|
||
<div class="input-group">
|
||
<input type="number" step="0.5" name="seat_depth" class="form-control powerchair-field"
|
||
t-att-value="assessment.seat_depth if assessment else ''"/>
|
||
<span class="input-group-text">Inch</span>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Legrest Length (Inches) <span class="text-danger">*</span></label>
|
||
<div class="input-group">
|
||
<input type="number" step="0.5" name="legrest_length" class="form-control powerchair-field"
|
||
t-att-value="assessment.legrest_length if assessment else ''"/>
|
||
<span class="input-group-text">Inch</span>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Seat to Floor Height (Inches) <span class="text-danger">*</span></label>
|
||
<div class="input-group">
|
||
<input type="number" step="0.5" name="seat_to_floor_height" class="form-control powerchair-field"
|
||
t-att-value="assessment.seat_to_floor_height if assessment else ''"/>
|
||
<span class="input-group-text">Inch</span>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<div class="row mb-4">
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Back Height (Inches) <span class="text-danger">*</span></label>
|
||
<div class="input-group">
|
||
<input type="number" step="0.5" name="back_height" class="form-control powerchair-field"
|
||
t-att-value="assessment.back_height if assessment else ''"/>
|
||
<span class="input-group-text">Inch</span>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Powerchair Seat Belt Type (same as wheelchair) -->
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Seat Belt Type – ADP Funded Options</label>
|
||
<div class="row">
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="standard" class="form-check-input" id="pc_belt_standard"
|
||
t-att-checked="assessment.seatbelt_type == 'standard' if assessment else False"/>
|
||
<label class="form-check-label" for="pc_belt_standard">Standard Belt – No Padding</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="padded" class="form-check-input" id="pc_belt_padded"
|
||
t-att-checked="assessment.seatbelt_type == 'padded' if assessment else False"/>
|
||
<label class="form-check-label" for="pc_belt_padded">Padded Belt – Positioning Belts (Modular)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="4point" class="form-check-input" id="pc_belt_4point"
|
||
t-att-checked="assessment.seatbelt_type == '4point' if assessment else False"/>
|
||
<label class="form-check-label" for="pc_belt_4point">4 Point Seat Belt – Positioning Belts (Modular)</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="chest_harness" class="form-check-input" id="pc_belt_chest"
|
||
t-att-checked="assessment.seatbelt_type == 'chest_harness' if assessment else False"/>
|
||
<label class="form-check-label" for="pc_belt_chest">Chest Harness – Positioning Belts (Modular)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="radio" name="seatbelt_type" value="additional_pads" class="form-check-input" id="pc_belt_pads"
|
||
t-att-checked="assessment.seatbelt_type == 'additional_pads' if assessment else False"/>
|
||
<label class="form-check-label" for="pc_belt_pads">Additional Pads – Positioning Belts (Custom)</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Powerchair Additional Options -->
|
||
<t t-set="powerchair_options_list" t-value="(assessment.powerchair_options or '').split(',') if assessment else []"/>
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Powerchair – Additional ADP Funded Options</label>
|
||
<div class="row">
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Adjustable Tension Back Upholstery" class="form-check-input" id="pc_tension"
|
||
t-att-checked="'Adjustable Tension Back Upholstery' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_tension">Adjustable Tension Back Upholstery</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Midline Control" class="form-check-input" id="pc_midline"
|
||
t-att-checked="'Midline Control' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_midline">Midline Control</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Manual Recline Option" class="form-check-input" id="pc_recline"
|
||
t-att-checked="'Manual Recline Option' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_recline">Manual Recline Option</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Angle Adjustable Footplates (pair)" class="form-check-input" id="pc_angle"
|
||
t-att-checked="'Angle Adjustable Footplates' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_angle">Angle Adjustable Footplates (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Manual Elevating Legrests (pair)" class="form-check-input" id="pc_elevating"
|
||
t-att-checked="'Manual Elevating Legrests' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_elevating">Manual Elevating Legrests (pair)</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Swingaway Mounting Bracket" class="form-check-input" id="pc_swingaway"
|
||
t-att-checked="'Swingaway Mounting Bracket' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_swingaway">Swingaway Mounting Bracket - Required**</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="One Piece 90/90 Front Riggings" class="form-check-input" id="pc_onepiece"
|
||
t-att-checked="'One Piece 90/90 Front Riggings' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_onepiece">One Piece 90/90 Front Riggings - Required**</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Seat Package 1 for Power Bases" class="form-check-input" id="pc_seat1"
|
||
t-att-checked="'Seat Package 1 for Power Bases' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_seat1">Seat Package 1 for Power Bases - Required**</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Seat Package 2 for Power Bases" class="form-check-input" id="pc_seat2"
|
||
t-att-checked="'Seat Package 2 for Power Bases' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_seat2">Seat Package 2 for Power Bases</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Oxygen Tank Holder" class="form-check-input" id="pc_o2"
|
||
t-att-checked="'Oxygen Tank Holder' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_o2">Oxygen Tank Holder</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="powerchair_options" value="Ventilator Tray" class="form-check-input" id="pc_vent"
|
||
t-att-checked="'Ventilator Tray' in powerchair_options_list"/>
|
||
<label class="form-check-label" for="pc_vent">Ventilator Tray</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Specialty Components -->
|
||
<t t-set="specialty_list" t-value="(assessment.specialty_controls or '').split(',') if assessment else []"/>
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Specialty Components (Rationale Required for these options)</label>
|
||
<div class="row">
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="specialty_controls" value="Specialty Controls 1 Non Standard Joystick" class="form-check-input" id="spec_1"
|
||
t-att-checked="'Specialty Controls 1' in specialty_list"/>
|
||
<label class="form-check-label" for="spec_1">Specialty Controls 1 Non Standard Joystick</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="specialty_controls" value="Specialty Controls 2 Chin/Rim Control" class="form-check-input" id="spec_2"
|
||
t-att-checked="'Specialty Controls 2' in specialty_list"/>
|
||
<label class="form-check-label" for="spec_2">Specialty Controls 2 Chin/Rim Control</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="specialty_controls" value="Specialty Controls 3 Simple Touch" class="form-check-input" id="spec_3"
|
||
t-att-checked="'Specialty Controls 3' in specialty_list"/>
|
||
<label class="form-check-label" for="spec_3">Specialty Controls 3 Simple Touch</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="specialty_controls" value="Specialty Controls 4 Proximity Control" class="form-check-input" id="spec_4"
|
||
t-att-checked="'Specialty Controls 4' in specialty_list"/>
|
||
<label class="form-check-label" for="spec_4">Specialty Controls 4 Proximity Control</label>
|
||
</div>
|
||
</div>
|
||
<div class="col-12 col-md-6">
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="specialty_controls" value="Specialty Controls 5 Breath Control" class="form-check-input" id="spec_5"
|
||
t-att-checked="'Specialty Controls 5' in specialty_list"/>
|
||
<label class="form-check-label" for="spec_5">Specialty Controls 5 Breath Control</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="specialty_controls" value="Specialty Controls 6 Scanners" class="form-check-input" id="spec_6"
|
||
t-att-checked="'Specialty Controls 6' in specialty_list"/>
|
||
<label class="form-check-label" for="spec_6">Specialty Controls 6 Scanners</label>
|
||
</div>
|
||
<div class="form-check mb-2">
|
||
<input type="checkbox" name="specialty_controls" value="Auto Correction System" class="form-check-input" id="spec_auto"
|
||
t-att-checked="'Auto Correction System' in specialty_list"/>
|
||
<label class="form-check-label" for="spec_auto">Auto Correction System</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Additional Information -->
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Additional Information/Customization</label>
|
||
<textarea name="additional_customization" class="form-control powerchair-field" rows="4" placeholder="Enter any additional requirements or customization notes..."><t t-esc="assessment.additional_customization if assessment else ''"/></textarea>
|
||
</div>
|
||
|
||
<!-- Power-mobility home-accessibility — ADP hard rule -->
|
||
<div class="mb-4 p-3 border rounded bg-light">
|
||
<label class="form-label fw-bold">Home accessible for the device — inside & outside?</label>
|
||
<select name="x_fc_power_home_accessible" class="form-control">
|
||
<option value="">-- Select --</option>
|
||
<option value="yes" t-att-selected="assessment.x_fc_power_home_accessible == 'yes' if assessment else False">Yes — usable inside and outside independently</option>
|
||
<option value="no" t-att-selected="assessment.x_fc_power_home_accessible == 'no' if assessment else False">No — home needs accessibility work</option>
|
||
</select>
|
||
<div class="alert alert-warning mt-2 mb-0">
|
||
<i class="fa fa-exclamation-triangle"/> ADP funds power mobility only if the device can enter and be used at the residence <strong>independently, without lifting</strong> (not left outside / in the garage). If <strong>No</strong>, add an accessibility assessment (ramp / porch lift) for the home.
|
||
</div>
|
||
<textarea name="x_fc_power_home_access_notes" class="form-control mt-2" rows="2" placeholder="Access notes (entry steps, garage, thresholds, turning space...)"><t t-esc="assessment.x_fc_power_home_access_notes if assessment else ''"/></textarea>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- ===== MOBILITY SCOOTER ===== -->
|
||
<div id="scooter_form" class="equipment-form" style="display: none;">
|
||
<h2 class="text-center fw-bold text-uppercase mb-4">Mobility Scooter Assessment</h2>
|
||
<div class="mb-4">
|
||
<label class="form-label fw-bold">Scooter Type</label>
|
||
<select name="scooter_type" class="form-select">
|
||
<option value="">-- Select Type --</option>
|
||
<option value="travel_3" t-att-selected="assessment.scooter_type == 'travel_3' if assessment else False">3-Wheel Travel/Portable</option>
|
||
<option value="travel_4" t-att-selected="assessment.scooter_type == 'travel_4' if assessment else False">4-Wheel Travel/Portable</option>
|
||
<option value="standard_3" t-att-selected="assessment.scooter_type == 'standard_3' if assessment else False">3-Wheel Standard</option>
|
||
<option value="standard_4" t-att-selected="assessment.scooter_type == 'standard_4' if assessment else False">4-Wheel Standard</option>
|
||
<option value="heavy_duty" t-att-selected="assessment.scooter_type == 'heavy_duty' if assessment else False">Heavy-Duty / Bariatric</option>
|
||
</select>
|
||
</div>
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Maximum Range Needed (km)</label>
|
||
<div class="input-group">
|
||
<input type="number" step="1" name="scooter_max_range" class="form-control"
|
||
t-att-value="assessment.scooter_max_range if assessment else ''"/>
|
||
<span class="input-group-text">km</span>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Power-mobility home-accessibility — ADP hard rule -->
|
||
<div class="mb-4 p-3 border rounded bg-light">
|
||
<label class="form-label fw-bold">Home accessible for the device — inside & outside?</label>
|
||
<select name="x_fc_power_home_accessible" class="form-control">
|
||
<option value="">-- Select --</option>
|
||
<option value="yes" t-att-selected="assessment.x_fc_power_home_accessible == 'yes' if assessment else False">Yes — usable inside and outside independently</option>
|
||
<option value="no" t-att-selected="assessment.x_fc_power_home_accessible == 'no' if assessment else False">No — home needs accessibility work</option>
|
||
</select>
|
||
<div class="alert alert-warning mt-2 mb-0">
|
||
<i class="fa fa-exclamation-triangle"/> ADP funds power mobility only if the device can enter and be used at the residence <strong>independently, without lifting</strong> (not left outside / in the garage). If <strong>No</strong>, add an accessibility assessment (ramp / porch lift) for the home.
|
||
</div>
|
||
<textarea name="x_fc_power_home_access_notes" class="form-control mt-2" rows="2" placeholder="Access notes (entry steps, garage, thresholds, turning space...)"><t t-esc="assessment.x_fc_power_home_access_notes if assessment else ''"/></textarea>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Client Biographic Information Section -->
|
||
<div class="card shadow-sm">
|
||
<div class="card-header bg-primary text-white">
|
||
<h4 class="mb-0"><i class="fa fa-user me-2"/>Client Information</h4>
|
||
</div>
|
||
<div class="card-body">
|
||
|
||
<!-- Name Fields -->
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">First Name <span class="text-danger">*</span></label>
|
||
<input type="text" name="client_first_name" class="form-control" required="required"
|
||
t-att-value="assessment.client_first_name if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Middle Name</label>
|
||
<input type="text" name="client_middle_name" class="form-control"
|
||
t-att-value="assessment.client_middle_name if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Last Name <span class="text-danger">*</span></label>
|
||
<input type="text" name="client_last_name" class="form-control" required="required"
|
||
t-att-value="assessment.client_last_name if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Client Type -->
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Client Type <span class="text-danger">*</span></label>
|
||
<select name="client_type" class="form-select" required="required">
|
||
<option value="reg" t-att-selected="(assessment.client_type if assessment else 'reg') == 'reg'">REG - Regular ADP</option>
|
||
<option value="ods" t-att-selected="assessment.client_type == 'ods' if assessment else False">ODS - ODSP</option>
|
||
<option value="acs" t-att-selected="assessment.client_type == 'acs' if assessment else False">ACS - ACSD</option>
|
||
<option value="owp" t-att-selected="assessment.client_type == 'owp' if assessment else False">OWP - Ontario Works</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-12 col-md-5 mb-3">
|
||
<label class="form-label fw-bold">Health Card Number <span class="text-danger">*</span></label>
|
||
<input type="text" name="client_health_card" class="form-control" required="required" placeholder="e.g. 1234-567-890"
|
||
t-att-value="assessment.client_health_card if assessment else ''"/>
|
||
</div>
|
||
<div class="col-6 col-md-3 mb-3">
|
||
<label class="form-label fw-bold">Version Code</label>
|
||
<input type="text" name="client_health_card_version" class="form-control" placeholder="e.g. AB"
|
||
t-att-value="assessment.client_health_card_version if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Address -->
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-8 mb-3">
|
||
<label class="form-label fw-bold">Street Address <span class="text-danger">*</span></label>
|
||
<input type="text" name="client_street" class="form-control" required="required"
|
||
t-att-value="assessment.client_street if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Unit/Apt/Suite</label>
|
||
<input type="text" name="client_unit" class="form-control" placeholder="e.g., Unit 5, Apt 302"
|
||
t-att-value="assessment.client_unit if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">City <span class="text-danger">*</span></label>
|
||
<input type="text" name="client_city" class="form-control" required="required"
|
||
t-att-value="assessment.client_city if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Province <span class="text-danger">*</span></label>
|
||
<select name="client_state" class="form-select" required="required">
|
||
<t t-foreach="provinces" t-as="prov">
|
||
<option t-att-value="prov[0]" t-att-selected="(assessment.client_state if assessment else 'Ontario') == prov[0]">
|
||
<t t-esc="prov[1]"/>
|
||
</option>
|
||
</t>
|
||
</select>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Postal Code <span class="text-danger">*</span></label>
|
||
<input type="text" name="client_postal_code" class="form-control" required="required" placeholder="A1A 1A1"
|
||
t-att-value="assessment.client_postal_code if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Contact -->
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Phone Number <span class="text-danger">*</span></label>
|
||
<input type="tel" name="client_phone" class="form-control" required="required" placeholder="(416) 555-1234"
|
||
t-att-value="assessment.client_phone if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Email</label>
|
||
<input type="email" name="client_email" class="form-control" placeholder="client@example.com"
|
||
t-att-value="assessment.client_email if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Client Weight (lbs)</label>
|
||
<input type="number" step="1" name="client_weight" class="form-control" placeholder="e.g., 180"
|
||
t-att-value="int(assessment.client_weight) if assessment and assessment.client_weight else ''"/>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Assessment Dates and Details Section -->
|
||
<div class="card shadow-sm">
|
||
<div class="card-header bg-primary text-white">
|
||
<h4 class="mb-0"><i class="fa fa-calendar me-2"/>Assessment Details</h4>
|
||
</div>
|
||
<div class="card-body">
|
||
|
||
<!-- Key Dates -->
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Assessment Start Date <span class="text-danger">*</span></label>
|
||
<input type="date" name="assessment_start_date" id="assessment_start_date" class="form-control" required="required"
|
||
t-att-value="assessment.assessment_start_date if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Assessment End Date</label>
|
||
<input type="date" name="assessment_end_date" class="form-control"
|
||
t-att-value="assessment.assessment_end_date if assessment else ''"/>
|
||
</div>
|
||
<div class="col-12 col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Claim Authorization Date</label>
|
||
<input type="date" name="claim_authorization_date" class="form-control"
|
||
t-att-value="assessment.claim_authorization_date if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Reason for Application -->
|
||
<div class="row mb-3">
|
||
<div class="col-12 col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Reason for Application</label>
|
||
<select name="reason_for_application" id="reason_for_application" class="form-select">
|
||
<option value="">-- Select Reason --</option>
|
||
<option value="first_access" t-att-selected="assessment.reason_for_application == 'first_access' if assessment else False">First Time Access - NO previous ADP</option>
|
||
<option value="additions" t-att-selected="assessment.reason_for_application == 'additions' if assessment else False">Additions</option>
|
||
<option value="mod_non_adp" t-att-selected="assessment.reason_for_application == 'mod_non_adp' if assessment else False">Modification/Upgrade - Original NOT through ADP</option>
|
||
<option value="mod_adp" t-att-selected="assessment.reason_for_application == 'mod_adp' if assessment else False">Modification/Upgrade - Original through ADP</option>
|
||
<option value="replace_status" t-att-selected="assessment.reason_for_application == 'replace_status' if assessment else False">Replacement - Change in Status</option>
|
||
<option value="replace_size" t-att-selected="assessment.reason_for_application == 'replace_size' if assessment else False">Replacement - Change in Body Size</option>
|
||
<option value="replace_worn" t-att-selected="assessment.reason_for_application == 'replace_worn' if assessment else False">Replacement - Worn out (past useful life)</option>
|
||
<option value="replace_lost" t-att-selected="assessment.reason_for_application == 'replace_lost' if assessment else False">Replacement - Lost</option>
|
||
<option value="replace_stolen" t-att-selected="assessment.reason_for_application == 'replace_stolen' if assessment else False">Replacement - Stolen</option>
|
||
<option value="replace_damaged" t-att-selected="assessment.reason_for_application == 'replace_damaged' if assessment else False">Replacement - Damaged beyond repair</option>
|
||
<option value="replace_no_longer_meets" t-att-selected="assessment.reason_for_application == 'replace_no_longer_meets' if assessment else False">Replacement - No longer meets needs</option>
|
||
<option value="growth" t-att-selected="assessment.reason_for_application == 'growth' if assessment else False">Growth/Change in condition</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-12 col-md-6 mb-3" id="previous_funding_date_container" style="display: none;">
|
||
<label class="form-label fw-bold">Previous Funding Date (for replacements)</label>
|
||
<input type="date" name="previous_funding_date" class="form-control"
|
||
t-att-value="assessment.previous_funding_date if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Authorizer Selection (searchable) -->
|
||
<div class="mb-3">
|
||
<label class="form-label fw-bold">Authorizer/OT <span class="text-danger">*</span></label>
|
||
<input type="hidden" name="authorizer_id" id="authorizer_id_value"
|
||
t-att-value="assessment.authorizer_id.id if assessment and assessment.authorizer_id else ''"/>
|
||
<div class="position-relative" id="authorizer-search-wrapper">
|
||
<input type="text" id="authorizer-search" class="form-control"
|
||
placeholder="Type to search authorizer..."
|
||
autocomplete="off"
|
||
t-att-value="(assessment.authorizer_id.name + (' - ' + assessment.authorizer_id.email if assessment.authorizer_id.email else '')) if assessment and assessment.authorizer_id else ''"/>
|
||
<div id="authorizer-dropdown" class="dropdown-menu w-100 shadow-sm" style="max-height:220px;overflow-y:auto;display:none;"/>
|
||
</div>
|
||
<!-- Authorizer data passed to JS (JSON-safe from controller) -->
|
||
<script type="application/json" id="authorizer-data">
|
||
<t t-out="authorizers_json"/>
|
||
</script>
|
||
</div>
|
||
|
||
<!-- Assessment Photos -->
|
||
<div class="mb-3">
|
||
<label class="form-label fw-bold">
|
||
<i class="fa fa-camera me-1"/>Assessment Photos
|
||
</label>
|
||
<p class="text-muted small mb-2">Upload photos from the assessment (client measurements, equipment, etc.). These will be attached to the case.</p>
|
||
<input type="file" name="assessment_photos" class="form-control" accept="image/*" multiple="multiple"/>
|
||
<small class="text-muted">You can select multiple photos. Accepted formats: JPG, PNG, GIF</small>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
|
||
<!-- ============================================= -->
|
||
<!-- Page 11: Consent & Declaration Section -->
|
||
<!-- ============================================= -->
|
||
<div class="card shadow-sm">
|
||
<div class="card-header" style="background: linear-gradient(135deg, #2c3e50 0%, #3498db 100%); cursor: pointer;"
|
||
data-bs-toggle="collapse" data-bs-target="#page11Section">
|
||
<h4 class="mb-0 text-white">
|
||
<i class="fa fa-file-text me-2"/>ADP Consent & Declaration (Page 11)
|
||
<small class="ms-2 opacity-75">(Optional - click to expand)</small>
|
||
</h4>
|
||
</div>
|
||
<div id="page11Section" class="collapse">
|
||
<div class="card-body">
|
||
<div class="alert alert-info">
|
||
<i class="fa fa-info-circle me-1"/>
|
||
Complete this section to digitally sign Page 11 of the ADP application.
|
||
The client name and details are auto-filled from the information above.
|
||
</div>
|
||
|
||
<!-- Client Name Display (auto-filled) -->
|
||
<div class="mb-3 p-2 bg-light rounded">
|
||
<label class="form-label fw-bold small text-muted">Client Name (from above)</label>
|
||
<div id="page11_client_name_display" class="fw-bold" style="font-size: 16px;">
|
||
<t t-if="assessment and assessment.client_name">
|
||
<t t-esc="assessment.client_name"/>
|
||
</t>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Signed By: Applicant or Agent -->
|
||
<div class="mb-3">
|
||
<label class="form-label fw-bold">
|
||
Application signed by <span class="text-danger">*</span>
|
||
</label>
|
||
<div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="consent_signed_by"
|
||
id="consent_applicant" value="applicant"
|
||
t-att-checked="'checked' if not assessment or not assessment.consent_signed_by or assessment.consent_signed_by == 'applicant' else None"/>
|
||
<label class="form-check-label" for="consent_applicant">Applicant</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="consent_signed_by"
|
||
id="consent_agent" value="agent"
|
||
t-att-checked="'checked' if assessment and assessment.consent_signed_by == 'agent' else None"/>
|
||
<label class="form-check-label" for="consent_agent">Agent (on behalf of applicant)</label>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Agent Details (shown only when Agent is selected) -->
|
||
<div id="agent_details_section" style="display: none;">
|
||
<div class="card mb-3" style="border-color: #3498db;">
|
||
<div class="card-header bg-light">
|
||
<h6 class="mb-0"><i class="fa fa-user me-1"/>Agent Information</h6>
|
||
</div>
|
||
<div class="card-body">
|
||
<!-- Relationship -->
|
||
<div class="mb-3">
|
||
<label class="form-label fw-bold">Relationship to Applicant</label>
|
||
<select name="agent_relationship" class="form-select">
|
||
<option value="">-- Select --</option>
|
||
<option value="spouse"
|
||
t-att-selected="'selected' if assessment and assessment.agent_relationship == 'spouse' else None">Spouse</option>
|
||
<option value="parent"
|
||
t-att-selected="'selected' if assessment and assessment.agent_relationship == 'parent' else None">Parent(s)</option>
|
||
<option value="child"
|
||
t-att-selected="'selected' if assessment and assessment.agent_relationship == 'child' else None">Child</option>
|
||
<option value="power_of_attorney"
|
||
t-att-selected="'selected' if assessment and assessment.agent_relationship == 'power_of_attorney' else None">Power of Attorney</option>
|
||
<option value="public_guardian"
|
||
t-att-selected="'selected' if assessment and assessment.agent_relationship == 'public_guardian' else None">Public Guardian/Trustee</option>
|
||
</select>
|
||
</div>
|
||
|
||
<!-- Agent Name -->
|
||
<div class="row">
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Last Name</label>
|
||
<input type="text" name="agent_last_name" class="form-control"
|
||
t-att-value="assessment.agent_last_name if assessment else ''"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">First Name</label>
|
||
<input type="text" name="agent_first_name" class="form-control"
|
||
t-att-value="assessment.agent_first_name if assessment else ''"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Middle Initial</label>
|
||
<input type="text" name="agent_middle_initial" class="form-control" maxlength="2"
|
||
t-att-value="assessment.agent_middle_initial if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Agent Address -->
|
||
<div class="row">
|
||
<div class="col-md-2 mb-3">
|
||
<label class="form-label fw-bold">Unit</label>
|
||
<input type="text" name="agent_unit" class="form-control"
|
||
t-att-value="assessment.agent_unit if assessment else ''"/>
|
||
</div>
|
||
<div class="col-md-2 mb-3">
|
||
<label class="form-label fw-bold">Street No.</label>
|
||
<input type="text" name="agent_street_number" class="form-control"
|
||
t-att-value="assessment.agent_street_number if assessment else ''"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Street Name</label>
|
||
<input type="text" name="agent_street_name" class="form-control"
|
||
t-att-value="assessment.agent_street_name if assessment else ''"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">City</label>
|
||
<input type="text" name="agent_city" class="form-control"
|
||
t-att-value="assessment.agent_city if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Province</label>
|
||
<input type="text" name="agent_province" class="form-control"
|
||
t-att-value="assessment.agent_province if assessment else 'Ontario'"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Postal Code</label>
|
||
<input type="text" name="agent_postal_code" class="form-control"
|
||
t-att-value="assessment.agent_postal_code if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Agent Phone -->
|
||
<div class="row">
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Home Phone</label>
|
||
<input type="tel" name="agent_home_phone" class="form-control"
|
||
t-att-value="assessment.agent_home_phone if assessment else ''"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Business Phone</label>
|
||
<input type="tel" name="agent_business_phone" class="form-control"
|
||
t-att-value="assessment.agent_business_phone if assessment else ''"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Extension</label>
|
||
<input type="text" name="agent_phone_ext" class="form-control"
|
||
t-att-value="assessment.agent_phone_ext if assessment else ''"/>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Consent Declaration -->
|
||
<div class="mb-3">
|
||
<div class="card" style="border-color: #2c3e50;">
|
||
<div class="card-body" style="background: #f8f9fa; font-size: 13px; line-height: 1.6;">
|
||
<p class="mb-2"><strong>Declaration and Consent</strong></p>
|
||
<p class="mb-2">
|
||
I declare that the information I have given in this Application for Funding
|
||
Assistance is true and correct. I agree to repay any overpayment that may be
|
||
required if the information is not correct or complete. I authorize the Assistive
|
||
Devices Program to collect and use my personal information as described on the
|
||
Information Sheet.
|
||
</p>
|
||
<p class="mb-0">
|
||
I understand that this application will be reviewed by the Assistive Devices
|
||
Program and that I will be notified of the decision.
|
||
</p>
|
||
</div>
|
||
</div>
|
||
<div class="form-check mt-2">
|
||
<input type="checkbox" class="form-check-input" name="consent_declaration_accepted"
|
||
id="consent_declaration_accepted" value="1"
|
||
t-att-checked="'checked' if assessment and assessment.consent_declaration_accepted else None"/>
|
||
<label class="form-check-label fw-bold" for="consent_declaration_accepted">
|
||
I have read and agree to the above declaration
|
||
</label>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Signature Pad -->
|
||
<div class="mb-3">
|
||
<label class="form-label fw-bold">
|
||
<i class="fa fa-pencil me-1"/>Signature
|
||
</label>
|
||
<div class="signature-pad-container" style="border: 2px solid #2c3e50; border-radius: 8px; background: white; max-width: 400px;">
|
||
<canvas id="consent_signature_canvas"
|
||
style="width: 100%; height: 120px; cursor: crosshair; touch-action: none;"/>
|
||
</div>
|
||
<div class="mt-1">
|
||
<button type="button" class="btn btn-sm btn-outline-secondary" id="btn_clear_consent_signature">
|
||
<i class="fa fa-eraser me-1"/>Clear Signature
|
||
</button>
|
||
</div>
|
||
<input type="hidden" name="signature_page_11_data" id="signature_page_11_data"/>
|
||
</div>
|
||
|
||
<!-- Consent Date -->
|
||
<div class="row">
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Consent Date</label>
|
||
<input type="date" name="consent_date" id="consent_date" class="form-control"
|
||
t-att-value="str(assessment.consent_date) if assessment and assessment.consent_date else ''"/>
|
||
</div>
|
||
</div>
|
||
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Loaner Equipment Section -->
|
||
<div class="card shadow-sm">
|
||
<div class="card-header" style="background: linear-gradient(135deg, #667eea 0%, #764ba2 100%); cursor: pointer;"
|
||
data-bs-toggle="collapse" data-bs-target="#loanerSection">
|
||
<h4 class="mb-0 text-white">
|
||
<i class="fa fa-wheelchair me-2"/>Loaner Equipment
|
||
<small class="ms-2 opacity-75">(Optional - click to expand)</small>
|
||
</h4>
|
||
</div>
|
||
<div id="loanerSection" class="collapse">
|
||
<div class="card-body">
|
||
<div class="alert alert-info">
|
||
<i class="fa fa-info-circle me-1"/> Assign a loaner device to the client during the assessment.
|
||
You can select an existing product or quickly create a new one.
|
||
</div>
|
||
|
||
<!-- Toggle: Use existing or create new -->
|
||
<div class="mb-3">
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="loaner_mode" id="loaner_existing" value="existing" checked="checked"/>
|
||
<label class="form-check-label" for="loaner_existing">Select Existing Product</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input type="radio" class="form-check-input" name="loaner_mode" id="loaner_new" value="new"/>
|
||
<label class="form-check-label" for="loaner_new">Quick Create New Product</label>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Existing Product Selection -->
|
||
<div id="loaner_existing_fields">
|
||
<div class="row">
|
||
<div class="col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Loaner Product</label>
|
||
<select name="loaner_product_id" id="loaner_product_id" class="form-select">
|
||
<option value="">-- Select Product --</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Serial Number</label>
|
||
<select name="loaner_lot_id" id="loaner_lot_id" class="form-select">
|
||
<option value="">-- Select Serial --</option>
|
||
</select>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Quick Create New Product -->
|
||
<div id="loaner_new_fields" style="display: none;">
|
||
<div class="row">
|
||
<div class="col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Product Name</label>
|
||
<input type="text" name="loaner_new_product_name" id="loaner_new_product_name"
|
||
class="form-control" placeholder="e.g., Rollator Type 2"/>
|
||
</div>
|
||
<div class="col-md-6 mb-3">
|
||
<label class="form-label fw-bold">Serial Number</label>
|
||
<input type="text" name="loaner_new_serial" id="loaner_new_serial"
|
||
class="form-control" placeholder="e.g., SN-2024-001"/>
|
||
</div>
|
||
</div>
|
||
<button type="button" id="btn_create_loaner_product" class="btn btn-outline-primary mb-3">
|
||
<i class="fa fa-plus me-1"/> Create Product
|
||
</button>
|
||
<div id="loaner_create_result" style="display: none;"></div>
|
||
</div>
|
||
|
||
<!-- Common Loaner Fields -->
|
||
<div class="row">
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Loaner Period (Days)</label>
|
||
<input type="number" name="loaner_period_days" id="loaner_period_days"
|
||
class="form-control" value="7" min="1"/>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Checkout Condition</label>
|
||
<select name="loaner_condition" class="form-select">
|
||
<option value="excellent">Excellent</option>
|
||
<option value="good" selected="selected">Good</option>
|
||
<option value="fair">Fair</option>
|
||
<option value="needs_repair">Needs Repair</option>
|
||
</select>
|
||
</div>
|
||
<div class="col-md-4 mb-3">
|
||
<label class="form-label fw-bold">Notes</label>
|
||
<input type="text" name="loaner_notes" class="form-control" placeholder="Optional notes..."/>
|
||
</div>
|
||
</div>
|
||
|
||
<input type="hidden" name="loaner_checkout" id="loaner_checkout" value="0"/>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
<!-- Submit Button -->
|
||
<div class="card shadow-sm">
|
||
<div class="card-body text-center">
|
||
<button type="submit" name="action" value="submit" class="btn btn-success btn-lg px-5">
|
||
<t t-if="visit_id"><i class="fa fa-clipboard me-2"/>Save to Visit</t>
|
||
<t t-else=""><i class="fa fa-check me-2"/>Submit Assessment</t>
|
||
</button>
|
||
<a t-att-href="('/my/visit/%s' % visit_id) if visit_id else '/my/assessments'" class="btn btn-outline-secondary btn-lg px-4 ms-3">
|
||
Cancel
|
||
</a>
|
||
</div>
|
||
</div>
|
||
|
||
</form>
|
||
</div>
|
||
|
||
<!-- JavaScript for dynamic form -->
|
||
<script type="text/javascript">
|
||
document.addEventListener('DOMContentLoaded', function() {
|
||
// ── Authorizer searchable dropdown ──
|
||
(function() {
|
||
var dataEl = document.getElementById('authorizer-data');
|
||
var searchInput = document.getElementById('authorizer-search');
|
||
var hiddenInput = document.getElementById('authorizer_id_value');
|
||
var dropdown = document.getElementById('authorizer-dropdown');
|
||
if (!dataEl || !searchInput || !hiddenInput || !dropdown) return;
|
||
|
||
var authorizers = [];
|
||
try { authorizers = JSON.parse(dataEl.textContent); } catch(e) {}
|
||
|
||
function renderDropdown(query) {
|
||
var q = (query || '').toLowerCase();
|
||
var matches = authorizers.filter(function(a) {
|
||
return a.name.toLowerCase().indexOf(q) !== -1 ||
|
||
(a.email && a.email.toLowerCase().indexOf(q) !== -1);
|
||
});
|
||
if (!q) matches = authorizers; // show all when empty
|
||
dropdown.innerHTML = '';
|
||
if (!matches.length) {
|
||
dropdown.innerHTML = '<div class="dropdown-item text-muted">No matching authorizer</div>';
|
||
dropdown.style.display = 'block';
|
||
return;
|
||
}
|
||
matches.forEach(function(a) {
|
||
var item = document.createElement('a');
|
||
item.href = '#';
|
||
item.className = 'dropdown-item';
|
||
item.textContent = a.name + (a.email ? ' - ' + a.email : '');
|
||
item.dataset.id = a.id;
|
||
item.addEventListener('mousedown', function(e) {
|
||
e.preventDefault();
|
||
hiddenInput.value = a.id;
|
||
searchInput.value = a.name + (a.email ? ' - ' + a.email : '');
|
||
dropdown.style.display = 'none';
|
||
});
|
||
dropdown.appendChild(item);
|
||
});
|
||
dropdown.style.display = 'block';
|
||
}
|
||
|
||
searchInput.addEventListener('focus', function() {
|
||
renderDropdown(searchInput.value);
|
||
});
|
||
searchInput.addEventListener('input', function() {
|
||
hiddenInput.value = ''; // clear selection until they pick
|
||
renderDropdown(searchInput.value);
|
||
});
|
||
searchInput.addEventListener('blur', function() {
|
||
// Small delay so mousedown on dropdown fires first
|
||
setTimeout(function() { dropdown.style.display = 'none'; }, 200);
|
||
});
|
||
|
||
// Form validation: require a valid selection
|
||
var form = searchInput.closest('form');
|
||
if (form) {
|
||
form.addEventListener('submit', function(e) {
|
||
if (!hiddenInput.value) {
|
||
e.preventDefault();
|
||
searchInput.classList.add('is-invalid');
|
||
searchInput.focus();
|
||
alert('Please select an Authorizer/OT from the suggestions.');
|
||
} else {
|
||
searchInput.classList.remove('is-invalid');
|
||
}
|
||
});
|
||
}
|
||
})();
|
||
|
||
var equipmentSelect = document.getElementById('equipment_type');
|
||
var rollatorForm = document.getElementById('rollator_form');
|
||
var wheelchairForm = document.getElementById('wheelchair_form');
|
||
var powerchairForm = document.getElementById('powerchair_form');
|
||
var scooterForm = document.getElementById('scooter_form');
|
||
var wheelchairTypeSelect = document.querySelector('select[name="wheelchair_type"]');
|
||
var reasonSelect = document.getElementById('reason_for_application');
|
||
var previousFundingContainer = document.getElementById('previous_funding_date_container');
|
||
var assessmentStartDate = document.getElementById('assessment_start_date');
|
||
|
||
// Set default assessment start date to today if empty
|
||
if (assessmentStartDate && !assessmentStartDate.value) {
|
||
var today = new Date();
|
||
var year = today.getFullYear();
|
||
var month = String(today.getMonth() + 1).padStart(2, '0');
|
||
var day = String(today.getDate()).padStart(2, '0');
|
||
assessmentStartDate.value = year + '-' + month + '-' + day;
|
||
}
|
||
|
||
// Show/hide previous funding date based on reason for application
|
||
function handleReasonChange() {
|
||
if (!reasonSelect || !previousFundingContainer) return;
|
||
var reason = reasonSelect.value;
|
||
// Show previous funding date for all reasons EXCEPT first_access and empty
|
||
if (reason && reason !== 'first_access') {
|
||
previousFundingContainer.style.display = 'block';
|
||
} else {
|
||
previousFundingContainer.style.display = 'none';
|
||
}
|
||
}
|
||
|
||
if (reasonSelect) {
|
||
reasonSelect.addEventListener('change', handleReasonChange);
|
||
// Check on page load
|
||
handleReasonChange();
|
||
}
|
||
|
||
function disableFormInputs(form) {
|
||
if (!form) return;
|
||
form.style.display = 'none';
|
||
form.querySelectorAll('input, select, textarea').forEach(function(el) {
|
||
el.disabled = true;
|
||
if (el.hasAttribute('required')) {
|
||
el.removeAttribute('required');
|
||
el.dataset.wasRequired = 'true';
|
||
}
|
||
});
|
||
}
|
||
|
||
function enableFormInputs(form) {
|
||
if (!form) return;
|
||
form.style.display = 'block';
|
||
form.querySelectorAll('input, select, textarea').forEach(function(el) {
|
||
el.disabled = false;
|
||
if (el.dataset.wasRequired === 'true') {
|
||
el.setAttribute('required', 'required');
|
||
}
|
||
});
|
||
}
|
||
|
||
function showEquipmentForm() {
|
||
var value = equipmentSelect ? equipmentSelect.value : '';
|
||
|
||
disableFormInputs(rollatorForm);
|
||
disableFormInputs(wheelchairForm);
|
||
disableFormInputs(powerchairForm);
|
||
disableFormInputs(scooterForm);
|
||
|
||
if (value === 'rollator') {
|
||
enableFormInputs(rollatorForm);
|
||
} else if (value === 'wheelchair') {
|
||
enableFormInputs(wheelchairForm);
|
||
} else if (value === 'powerchair') {
|
||
enableFormInputs(powerchairForm);
|
||
} else if (value === 'scooter') {
|
||
enableFormInputs(scooterForm);
|
||
}
|
||
}
|
||
|
||
// Auto-select options for wheelchair types 2, 3, 4
|
||
function handleWheelchairTypeChange() {
|
||
if (!wheelchairTypeSelect) return;
|
||
var wcType = wheelchairTypeSelect.value;
|
||
|
||
// Types 2, 3, 4 should auto-select these options
|
||
if (wcType === 'type_2' || wcType === 'type_3' || wcType === 'type_4') {
|
||
// Quick Release Axles (pair)
|
||
var quickRelease = document.getElementById('wheel_quick');
|
||
if (quickRelease) quickRelease.checked = true;
|
||
|
||
// Angle Adjustable Footplates
|
||
var angleFootplates = document.getElementById('leg_angle');
|
||
if (angleFootplates) angleFootplates.checked = true;
|
||
|
||
// Padded Belt – Positioning Belts (Modular)
|
||
var paddedBelt = document.getElementById('belt_padded');
|
||
if (paddedBelt) paddedBelt.checked = true;
|
||
}
|
||
}
|
||
|
||
if (equipmentSelect) {
|
||
equipmentSelect.addEventListener('change', showEquipmentForm);
|
||
// Show initial form if value is set
|
||
showEquipmentForm();
|
||
}
|
||
|
||
if (wheelchairTypeSelect) {
|
||
wheelchairTypeSelect.addEventListener('change', handleWheelchairTypeChange);
|
||
// Apply on load if already set
|
||
handleWheelchairTypeChange();
|
||
}
|
||
});
|
||
</script>
|
||
|
||
<!-- Google Maps Places API for Address Autocomplete -->
|
||
<t t-if="google_maps_api_key">
|
||
<script t-attf-src="https://maps.googleapis.com/maps/api/js?key=#{google_maps_api_key}&libraries=places&callback=initExpressAddressAutocomplete" async="async" defer="defer"></script>
|
||
</t>
|
||
|
||
<script type="text/javascript">
|
||
function initExpressAddressAutocomplete() {
|
||
var streetInput = document.querySelector('input[name="client_street"]');
|
||
if (!streetInput) return;
|
||
|
||
var autocomplete = new google.maps.places.Autocomplete(streetInput, {
|
||
componentRestrictions: { country: 'ca' },
|
||
types: ['address']
|
||
});
|
||
|
||
autocomplete.addListener('place_changed', function() {
|
||
var place = autocomplete.getPlace();
|
||
if (!place.address_components) return;
|
||
|
||
var streetNumber = '';
|
||
var streetName = '';
|
||
var city = '';
|
||
var province = '';
|
||
var postalCode = '';
|
||
|
||
for (var i = 0; i < place.address_components.length; i++) {
|
||
var component = place.address_components[i];
|
||
var types = component.types;
|
||
|
||
if (types.includes('street_number')) {
|
||
streetNumber = component.long_name;
|
||
} else if (types.includes('route')) {
|
||
streetName = component.long_name;
|
||
} else if (types.includes('locality')) {
|
||
city = component.long_name;
|
||
} else if (types.includes('administrative_area_level_1')) {
|
||
province = component.long_name;
|
||
} else if (types.includes('postal_code')) {
|
||
postalCode = component.long_name;
|
||
}
|
||
}
|
||
|
||
// Update street address field with full street
|
||
streetInput.value = (streetNumber + ' ' + streetName).trim();
|
||
|
||
// Update city field
|
||
var cityInput = document.querySelector('input[name="client_city"]');
|
||
if (cityInput) cityInput.value = city;
|
||
|
||
// Update province select
|
||
var provinceSelect = document.querySelector('select[name="client_state"]');
|
||
if (provinceSelect) {
|
||
// Try to match province name
|
||
for (var j = 0; j < provinceSelect.options.length; j++) {
|
||
if (provinceSelect.options[j].text.toLowerCase() === province.toLowerCase() ||
|
||
provinceSelect.options[j].value.toLowerCase() === province.toLowerCase()) {
|
||
provinceSelect.selectedIndex = j;
|
||
break;
|
||
}
|
||
}
|
||
}
|
||
|
||
// Update postal code field
|
||
var postalInput = document.querySelector('input[name="client_postal_code"]');
|
||
if (postalInput) postalInput.value = postalCode;
|
||
});
|
||
}
|
||
|
||
// Fallback if Google Maps not loaded
|
||
window.initExpressAddressAutocomplete = window.initExpressAddressAutocomplete || function() {};
|
||
|
||
// ============================================================
|
||
// PAGE 11: Consent & Declaration Section Logic
|
||
// ============================================================
|
||
(function() {
|
||
var consentApplicant = document.getElementById('consent_applicant');
|
||
var consentAgent = document.getElementById('consent_agent');
|
||
var agentSection = document.getElementById('agent_details_section');
|
||
var consentDateInput = document.getElementById('consent_date');
|
||
var signatureCanvas = document.getElementById('consent_signature_canvas');
|
||
var signatureDataInput = document.getElementById('signature_page_11_data');
|
||
var clearBtn = document.getElementById('btn_clear_consent_signature');
|
||
var consentSignaturePad = null;
|
||
|
||
// Toggle agent details based on signer selection
|
||
function handleSignerChange() {
|
||
if (!agentSection) return;
|
||
var isAgent = consentAgent && consentAgent.checked;
|
||
agentSection.style.display = isAgent ? 'block' : 'none';
|
||
}
|
||
|
||
if (consentApplicant) {
|
||
consentApplicant.addEventListener('change', handleSignerChange);
|
||
}
|
||
if (consentAgent) {
|
||
consentAgent.addEventListener('change', handleSignerChange);
|
||
}
|
||
// Check on load (for edit mode)
|
||
handleSignerChange();
|
||
|
||
// Default consent date to today
|
||
if (consentDateInput && !consentDateInput.value) {
|
||
var today = new Date();
|
||
consentDateInput.value = today.getFullYear() + '-' +
|
||
String(today.getMonth() + 1).padStart(2, '0') + '-' +
|
||
String(today.getDate()).padStart(2, '0');
|
||
}
|
||
|
||
// Initialize signature pad
|
||
// Strategy: try on collapse show, on click/touch of canvas, and with a retry
|
||
function initSignaturePad() {
|
||
if (consentSignaturePad) return true;
|
||
if (!signatureCanvas) return false;
|
||
// Canvas must be visible and have dimensions
|
||
var rect = signatureCanvas.getBoundingClientRect();
|
||
if (rect.width < 10 || rect.height < 10) return false;
|
||
// Try window.SignaturePad (set by signature_pad.js)
|
||
if (window.SignaturePad) {
|
||
consentSignaturePad = new window.SignaturePad(signatureCanvas);
|
||
return true;
|
||
}
|
||
// Fallback: build a minimal inline signature pad
|
||
var ctx = signatureCanvas.getContext('2d');
|
||
var ratio = window.devicePixelRatio || 1;
|
||
signatureCanvas.width = rect.width * ratio;
|
||
signatureCanvas.height = rect.height * ratio;
|
||
ctx.scale(ratio, ratio);
|
||
signatureCanvas.style.width = rect.width + 'px';
|
||
signatureCanvas.style.height = rect.height + 'px';
|
||
ctx.strokeStyle = '#000';
|
||
ctx.lineWidth = 2;
|
||
ctx.lineCap = 'round';
|
||
ctx.lineJoin = 'round';
|
||
ctx.fillStyle = '#fff';
|
||
ctx.fillRect(0, 0, signatureCanvas.width, signatureCanvas.height);
|
||
var drawing = false;
|
||
var lastX = 0, lastY = 0;
|
||
var hasPoints = false;
|
||
function getPos(e) {
|
||
var r = signatureCanvas.getBoundingClientRect();
|
||
var t = e.touches ? e.touches[0] : e;
|
||
return { x: t.clientX - r.left, y: t.clientY - r.top };
|
||
}
|
||
function down(e) { e.preventDefault(); drawing = true; var p = getPos(e); lastX = p.x; lastY = p.y; hasPoints = true; }
|
||
function move(e) { e.preventDefault(); if (!drawing) return; var p = getPos(e); ctx.beginPath(); ctx.moveTo(lastX, lastY); ctx.lineTo(p.x, p.y); ctx.stroke(); lastX = p.x; lastY = p.y; }
|
||
function up(e) { e.preventDefault(); drawing = false; }
|
||
signatureCanvas.addEventListener('mousedown', down);
|
||
signatureCanvas.addEventListener('mousemove', move);
|
||
signatureCanvas.addEventListener('mouseup', up);
|
||
signatureCanvas.addEventListener('mouseout', up);
|
||
signatureCanvas.addEventListener('touchstart', down, {passive:false});
|
||
signatureCanvas.addEventListener('touchmove', move, {passive:false});
|
||
signatureCanvas.addEventListener('touchend', up, {passive:false});
|
||
// Create a compatible API
|
||
consentSignaturePad = {
|
||
clear: function() { ctx.fillStyle='#fff'; ctx.fillRect(0,0,signatureCanvas.width,signatureCanvas.height); hasPoints=false; ctx.strokeStyle='#000'; ctx.lineWidth=2; ctx.lineCap='round'; },
|
||
isEmpty: function() { return !hasPoints; },
|
||
toDataURL: function(type) { return signatureCanvas.toDataURL(type || 'image/png'); }
|
||
};
|
||
return true;
|
||
}
|
||
|
||
// Try init on collapse show
|
||
var page11Section = document.getElementById('page11Section');
|
||
if (page11Section) {
|
||
page11Section.addEventListener('shown.bs.collapse', function() {
|
||
setTimeout(initSignaturePad, 100);
|
||
});
|
||
// Also try on any click inside the section
|
||
page11Section.addEventListener('click', function() {
|
||
initSignaturePad();
|
||
});
|
||
}
|
||
|
||
// Also try init when canvas is touched/clicked directly
|
||
if (signatureCanvas) {
|
||
signatureCanvas.addEventListener('mousedown', function() { initSignaturePad(); }, { once: true });
|
||
signatureCanvas.addEventListener('touchstart', function() { initSignaturePad(); }, { once: true });
|
||
}
|
||
|
||
// Retry a few times after page load
|
||
var retryCount = 0;
|
||
var retryInterval = setInterval(function() {
|
||
retryCount++;
|
||
if (initSignaturePad() || retryCount > 20) {
|
||
clearInterval(retryInterval);
|
||
}
|
||
}, 500);
|
||
|
||
// Clear signature button
|
||
if (clearBtn) {
|
||
clearBtn.addEventListener('click', function() {
|
||
if (consentSignaturePad) {
|
||
consentSignaturePad.clear();
|
||
}
|
||
});
|
||
}
|
||
|
||
// Auto-populate client name display in Page 11
|
||
function updatePage11ClientName() {
|
||
var display = document.getElementById('page11_client_name_display');
|
||
if (!display) return;
|
||
var first = document.querySelector('input[name="client_first_name"]');
|
||
var middle = document.querySelector('input[name="client_middle_name"]');
|
||
var last = document.querySelector('input[name="client_last_name"]');
|
||
var parts = [];
|
||
if (first && first.value) parts.push(first.value);
|
||
if (middle && middle.value) parts.push(middle.value);
|
||
if (last && last.value) parts.push(last.value);
|
||
display.textContent = parts.join(' ') || '(enter client name above)';
|
||
}
|
||
|
||
// Listen for name field changes
|
||
['client_first_name', 'client_middle_name', 'client_last_name'].forEach(function(fieldName) {
|
||
var el = document.querySelector('input[name="' + fieldName + '"]');
|
||
if (el) {
|
||
el.addEventListener('input', updatePage11ClientName);
|
||
}
|
||
});
|
||
updatePage11ClientName();
|
||
|
||
// Before form submit: capture signature as base64
|
||
var form = document.querySelector('form[action*="express/save"]');
|
||
if (form) {
|
||
form.addEventListener('submit', function() {
|
||
if (consentSignaturePad && !consentSignaturePad.isEmpty() && signatureDataInput) {
|
||
signatureDataInput.value = consentSignaturePad.toDataURL('image/png');
|
||
}
|
||
});
|
||
}
|
||
})();
|
||
</script>
|
||
</t>
|
||
</template>
|
||
|
||
</odoo>
|