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<?php include "header2.php";?>
<?php
// memulai session
//jika session belum dibuat, maka inisialisasi awal diberi nilai TRUE
if (!isset($_SESSION['submit'])) {
$_SESSION['submit'] = true;
}
?>
<link rel="icon" href="idilogo.png">
<style type="text/css">
<!--
-->
html{
background-size: cover;
height:100%;
font-size: 12px;
}
#feedback-page{
text-align:center;
}
#form-main{
width:100%;
float:left;
padding-top:0px;
}
#form-div {
background-image: linear-gradient(to right, #4682B4, #00FFFF, #00FA9A);
background:url(image/tdoc.jpg) no-repeat;
padding-left:35px;
padding-right:35px;
padding-top:35px;
padding-bottom:50px;
width: 800px;
float: left;
left: 50%;
margin-top:30px;
margin-left: 5px;
-moz-border-radius: 7px;
-webkit-border-radius: 7px;
border: 1px solid #dedede;
}
.feedback-input {
color:#3c3c3c;
font-family: Helvetica, Arial, sans-serif;
font-weight:500;
font-size: 18px;
border-radius: 0;
line-height: 22px;
background-color: #fbfbfb;
padding: 13px 13px 13px 54px;
margin-bottom: 10px;
width:100%;
-webkit-box-sizing: border-box;
-moz-box-sizing: border-box;
-ms-box-sizing: border-box;
box-sizing: border-box;
border: 3px solid rgba(0,0,0,0);
}
.feedback-input:focus{
background: #fff;
box-shadow: 0;
border: 3px solid #3498db;
color: #3498db;
outline: none;
padding: 13px 13px 13px 54px;
}
.focused{
color:#30aed6;
border:#30aed6 solid 3px;
}
/* Icons ---------------------------------- */
#name{
background-image: url(http://rexkirby.com/kirbyandson/images/name.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#name:focus{
background-image: url(http://rexkirby.com/kirbyandson/images/name.svg);
background-size: 30px 30px;
background-position: 8px 5px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#email{
background-image: url(http://rexkirby.com/kirbyandson/images/email.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#email:focus{
background-image: url(http://rexkirby.com/kirbyandson/images/email.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#comment{
background-image: url(http://rexkirby.com/kirbyandson/images/comment.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
.textarea {
width: 100%;
height: 150px;
line-height: 150%;
resize:vertical;
padding: 10px;
}
.merah {
color: red;
}
input:hover, textarea:hover,
input:focus, textarea:focus {
background-color:white;
}
#button-blue{
font-family: 'Montserrat', Arial, Helvetica, sans-serif;
float:left;
width: 100%;
border: #fbfbfb solid 4px;
cursor:pointer;
background-color: #3498db;
color:white;
font-size:24px;
padding-top:22px;
padding-bottom:22px;
-webkit-transition: all 0.3s;
-moz-transition: all 0.3s;
transition: all 0.3s;
margin-top:-4px;
margin-left:5px;
font-weight:700;
}
#button-blue:hover{
background-color: rgba(0,0,0,0);
color: #0493bd;
}
.submit:hover {
color: #3498db;
}
.ease {
width: 0px;
height: 74px;
background-color: #fbfbfb;
-webkit-transition: .3s ease;
-moz-transition: .3s ease;
-o-transition: .3s ease;
-ms-transition: .3s ease;
transition: .3s ease;
}
.submit:hover .ease{
width:100%;
background-color:#EEE;
}
/* Icons ---------------------------------- */
#name{
background-image: url(http://rexkirby.com/kirbyandson/images/name.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#name:focus{
background-image: url(http://rexkirby.com/kirbyandson/images/name.svg);
background-size: 30px 30px;
background-position: 8px 5px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#email{
background-image: url(http://rexkirby.com/kirbyandson/images/email.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#email:focus{
background-image: url(http://rexkirby.com/kirbyandson/images/email.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#comment{
background-image: url(http://rexkirby.com/kirbyandson/images/comment.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
@media only screen and (max-width: 580px) {
#form-div{
left: 3%;
margin-right: 3%;
width: 88%;
margin-left: 3%;
padding-left: 3%;
padding-right: 3%;
font-size: 14px;
}
</style>
<link rel="stylesheet" href="//code.jquery.com/ui/1.12.1/themes/base/jquery-ui.css">
<link rel="stylesheet" href="//code.jquery.com/ui/1.12.1/themes/base/jquery-ui.css">
<script src="https://code.jquery.com/jquery-1.12.4.js"></script>
<script src="https://code.jquery.com/ui/1.12.1/jquery-ui.js"></script>
<script>
<!--
$( function() {
$( "#datepicker1" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker2" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker3" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker4" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker5" ).datepicker({ dateFormat: 'dd-mm-yy' });
} );
function MM_findObj(n, d) { //v4.01
var p,i,x; if(!d) d=document; if((p=n.indexOf("?"))>0&&parent.frames.length) {
d=parent.frames[n.substring(p+1)].document; n=n.substring(0,p);}
if(!(x=d[n])&&d.all) x=d.all[n]; for (i=0;!x&&i<d.forms.length;i++) x=d.forms[i][n];
for(i=0;!x&&d.layers&&i<d.layers.length;i++) x=MM_findObj(n,d.layers[i].document);
if(!x && d.getElementById) x=d.getElementById(n); return x;
}
//-->
</script>
<title>Ikatan Dokter Indonesia</title>
<body>
<div id="wrapper">
<?php // include "sidebar.php"; ?>
<!-- Content Wrapper -->
<div id="content-wrapper" class="d-flex flex-column">
<!-- Main Content -->
<div id="content">
<?php //include "topbar.php";?>
<!-- Begin Page Content -->
<div class="container-fluid">
<!-- DataTales Example -->
<div class="card shadow mb-4">
<div class="card-header py-3">
<h6 class="m-0 font-weight-bold text-primary">List Post</h6>
</div>
<div class="card-body">
<div class="table-responsive">
<div class="container">
<div id="form-div">
<CENTER><strong class="h2"> REGISTRASI</strong></CENTER>
<p><label for=""></label> </p>
<br>
<?php
$tglBayar = date('Y-m-d');
$hari = date('Y-m-d');
$npm = $_GET['npm'];
// //$nmlead = $_GET['nmlead'];
//
// $data = mysqli_query($konek, "SELECT * FROM h_anggota WHERE npm='$_GET[npm]' " );
// $d=mysqli_fetch_array($data);
$view = isset($d['npm']) ? $d['npm'] : null;
//menampilkan data Pra registrasi
$npm=$_GET['npm'];
$noreg=$_GET['noreg'];
$sql=mysqli_query($konek,"SELECT * FROM peserta where npm='$npm' AND noreg='$noreg' order by id desc limit 1 ");
$data=mysqli_fetch_array($sql);
//data hobi dari tabel siswa
// $datahobi=explode(',', $data['dokumen']);
$rs = isset($data['rs']) ? $data['rs'] : null;
$klinik = isset($data['klinik']) ? $data['klinik'] : null;
$puskesmas = isset($data['puskesmas']) ? $data['puskesmas'] : null;
$pribadi = isset($data['pribadi']) ? $data['pribadi'] : null;
$kota = isset($data['kota']) ? $data['kota'] : null;
$npm = $data['npm'] ;
$perihal = $data['perihal'];
$anggota = $data['anggota'];
$ahli = $data['ahli'];
$status = $data['status'];
$idp = $data['id'];
$status = $data['status'];
$jumlah = $data['jumlah'];
$instansi = $data['instansi'];
?>
<title>Persiapan Dokumen Rekomendasi </title>
<br>
<div class="card-body">
<div class="row">
<div class="col-md-6">
<div class="form-group ">
<strong>Status Keanggotaan IDI Bandung:</strong><br>
<input type="radio" name="anggota" value="tamu_IDI"<?php if($anggota=='tamu_IDI') echo 'checked'?> disabled> Non Anggota IDI Bandung/Tamu <br>
<input type="radio" name="anggota" value="internsip"<?php if($anggota=='internsip') echo 'checked'?> disabled> Internsip <br>
<br>
<strong>Status Kota :</strong><br>
<input type="radio" name="kota" value="bandung"<?php if($kota=='bandung') echo 'checked' ?> disabled> Kota Bandung<br>
<br>
<strong>Keahlian : </strong><br>
<input type="radio" name="ahli" value="dokter_umum"<?php if($ahli=='dokter_umum') echo 'checked'?> disabled> Dokter Umum <br>
<input type="radio" name="ahli" value="spesialis"<?php if($ahli=='spesialis') echo 'checked' ?> disabled> Dokter Spesialis<br>
<br>
<strong>Status Pengajuan :</strong><br>
<input type="radio" name="status" value="rekom_baru"<?php if($status=='rekom_baru') echo 'checked'?> disabled> Pengajuan Baru <br>
<input type="radio" name="status" value="rekom_revisi"<?php if($status=='rekom_revisi') echo 'checked'?> disabled> Revisi Jadwal Praktek<br>
<br> <br>
<strong>Pengajuan Jumlah Tempat Praktek : </strong><br>
<input type="radio" name="jumlah" value="1"<?php if($jumlah=='1') echo 'checked'?> disabled> 1 tempat Praktek Baru<br>
<input type="radio" name="jumlah" value="1"<?php if($jumlah=='2') echo 'checked'?> disabled> 2 tempat Praktek Baru<br>
<input type="radio" name="jumlah" value="1"<?php if($jumlah=='3') echo 'checked'?> disabled> 3 tempat Praktek Baru<br>
<br>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<strong>Jenis Pengajuan rekomendasi:</strong><br>
<input type="radio" name="perihal" value="rekomendasi_SIP_dr_umum"<?php if($perihal=='rekomendasi_SIP_dr_umum') echo 'checked'?> disabled> Rekomendasi SIP dr Umum <br>
<input type="radio" name="perihal" value="rekomendasi_SIP_dr_spesialis"<?php if($perihal=='rekomendasi_SIP_dr_spesialis') echo 'checked'?> disabled> Rekomendasi SIP dr Spesialis <br> <br>
<input type="radio" name="perihal" value="rekomendasi_PPDS"<?php if($perihal=='rekomendasi_PPDS') echo 'checked'?> disabled> Rekomendasi Daftar PPDS <br>
<input type="radio" name="perihal" value="rekomendasi_SIP_PPDS_I"<?php if($perihal=='rekomendasi_SIP_PPDS_I') echo 'checked'?> disabled> Rekomendasi SIP PPDS I<br>
<input type="radio" name="perihal" value="rekomendasi_PPDS_II"<?php if($perihal=='rekomendasi_PPDS_II') echo 'checked'?> disabled> Rekomendasi Daftar PPDS II<br>
<input type="radio" name="perihal" value="rekomendasi_SIP_PPDS_II"<?php if($perihal=='rekomendasi_SIP_PPDS_II') echo 'checked'?> disabled> Rekomendasi SIP PPDS II <br> <br>
<input type="radio" name="perihal" value="rekomendasi_fellowship"<?php if($perihal=='rekomendasi_fellowship') echo 'checked'?> disabled> Rekomendasi Fellowship<br>
<input type="radio" name="perihal" value="rekomendasi_internsip"<?php if($perihal=='rekomendasi_internsip') echo 'checked'?> disabled> Rekomendasi Internsip<br>
<br>
<strong>Tempat Sarana Kesehatan :</strong><br>
<label><input type="checkbox" name="rs" value="rumah_sakit" <?php if ("rumah_sakit"==$rs) echo "checked";?> disabled> Rumah Sakit</label><br>
<input type="checkbox" name="klinik" value="klinik"<?php if ("klinik"==$klinik) echo "checked";?> disabled> Klinik</label><br>
<input type="checkbox" name="puskesmas" value="puskesmas"<?php if ("puskesmas"==$puskesmas) echo "checked";?> disabled> Puskesmas</label><br>
<input type="checkbox" name="pribadi" value="pribadi"<?php if ("pribadi"==$pribadi) echo "checked";?> disabled> Pribadi</label><br>
<br>
</div>
</div>
<center></center><title><h4>INPUT DATA PRIBADI</h4> </title>
<?php
$tglBayar = date('Y-m-d');
$hari = date('Y-m-d');
$npm = $_GET['npm'];
//$nmlead = $_GET['nmlead'];
$data = mysqli_query($konek, "SELECT * FROM h_nonanggota WHERE npm='$_GET[npm]' " );
$d=mysqli_fetch_array($data);
$tglmbstr= $d['mbstr'];
$date = new DateTime($tglmbstr);
$mbstr= $date->format('d-m-Y');
$view = isset($d['npm']) ? $d['npm'] : null;
?>
<form method="post" action="reg_pros.php" enctype="multipart/form-data">
<div class="card-body">
<div class="row">
<div class="col-md-6">
<div class="form-group ">
<label for="tbayar">ID </label><br>
<p class="name"><input name="npm" readonly class="form-control" value="<?php echo $_GET['npm'] ?>" />
<p class="name"><input name="type" readonly class="form-control" value="3" />
</p>
<p class="name"><input name="noreg" readonly class="form-control" value="<?php echo $_GET['noreg'] ?>" />
</p>
<label for="tgl">Tanggal Registrasi</label>
<input name="tglreg" class="form-control" readonly type="text" value="<?php echo $hari ?>" size="11" />
</p>
<label for="nama">NPA</label>
<br>
<p class="name"><input name="npa" readonly placeholder="Isi Nomor NPA" class="form-control" value="<?php echo $d['npa']; ?> <?php echo $mbstr ?>" />
</p></p>Nomor STR <br>
<input name="nostr" type="text" class="form-control" placeholder="Isi No STR" maxlength="30" value="<?php echo $d['nostr']; ?>" />
</p>
</p ><span class="merah">Masa Berlaku Tanggal Akhir Nomor STR (MBSTR) sudah expired <br>(Mohon di update MBSTR yang terbaru)</span><br>
</p>Masa Berlaku Tanggal Akhir Nomor STR <br>(Format tampil: Bulan/Tanggal/Tahun, contoh: 29/12/2022)<br>
<input name="mbstr" id="datepicker1" class="form-control" placeholder="Isi Masa Berlaku Tanggal Akhir STR" value="<?php echo $mbstr ?>" required />
</p>
<label for="tbayar">Nomor KTP :</label>
<br>
<input class="form-control" name="ktp" type="teks" readonly placeholder="Isi Nomor KTP" value="<?php echo $d['ktp']; ?>" required />
</p>
<br>
<label for="tbayar"><p><b>Nama Lengkap dan Gelar (Wajib)<br>
contoh:<br>- Nama anda, dr.</b> <br> (contoh Dokter Umum)<br>
-<b> Nama anda, dr., Sp.PK </b><br> (contoh Dokter Spesialis)
</b></p></label>
<br>
<textarea name="nmlead" class="form-control" placeholder="Isi Nama lengkap (Gelar)" required><?php echo $d['nmlead'] ?></textarea>
</p>
<br>
<label for="tbayar"><p><b>Keahlian<br>
contoh:
<br>- Dokter Umum</b> <br> (Contoh Dokter umum)<br>
- <b>Dokter Spesialis Obstetri dan Ginekologi</b> <br> (Contoh Dokter Spesialis wajib lengkap)</p></label>
<textarea name="ahli" class="form-control" placeholder="Isi Keahlian Praktek sebagai" required><?php echo $d['ahli']; ?></textarea>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<div class="form-group">
<label for="kota">Status kota (untuk pengajuan di kota:)</label>
<br>
<input name="kota" type="text" class="form-control" value="<?php echo $kota ?>" readonly required />
</p>
<label for="Alamat">Alamat lengkap Sesuai dengan KTP atau SKTS :</label>
<br>
<textarea name="alamat" class="form-control" placeholder="Isi Alamat" required><?php echo $d['alamat']; ?></textarea>
</p>
<label for="telp ">Mobile no/WA contoh :628xxx</label>
<br>
<input name="telp" type="number" class="form-control" value="<?php echo $d['telp'] ?>" placeholder="Isi telp 628xxx" maxlength="30" required />
</p>
<label for="No Telpon">Alamat Email</label>
<br>
<input name="email" type="email" class="form-control" value="<?php echo $d['email'] ?>" placeholder="Isi email" required />
</p>
<label for="No Telpon">Asal Kota Cabang *kosongkan jika tidak ada </label>
<br>
<input name="asalcb" type="text" class="form-control" value="<?php echo $d['asalcb'] ?>" placeholder="Isi asal Kota Cabang" />
</p>
<label for="supervisor">Administrasi: </label><br>
<?php
$sqlKelas = mysqli_query($konek, "select * from level where kat_nm= '$perihal' order by level ASC");
$k=mysqli_fetch_array($sqlKelas);
$nominal = $k['nominal']*$jumlah ;
?>
<input name="level" type="text" class="form-control" readonly maxlength="30" value="<?php echo $k['kat_nm']; ?>" />
</P>
<?php
if( $perihal=='rekomendasi_internsip'){
?>
Administrasi Internsip : <?php echo $k['keterangan']?> </p>
<input name="nominal" type="text" class="form-control" readonly placeholder="nominal" maxlength="30" value="<?php echo $k['nominal']; ?>" />
<?php
}else{
?>
Jumlah Pengajuan SIP : <?php echo $jumlah ?> Tempat Praktek Baru ditambah Biaya pembinaan non anggota/tamu sebasar sisa Bulan Masa berlaku STR x nominal iuran bulanan.</p>
<input name="nominal" type="text" class="form-control" readonly placeholder="nominal" maxlength="30" value="<?php echo $nominal ?>" />
</br>
<?php
}
?>
</P>
<br>
</p>
<div class="submit">
<input type="submit" id="button-blue" value="Submit" />
<div class="ease"></div>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
<br> <br>
<!-- jQuery first, then Popper.js, then Bootstrap JS -->
</body>
<!-- proses edit data -->