<!DOCTYPE html>
<html xmlns="http://www.w3.org/1999/xhtml" lang="en-US">
<head>
<title>Request for HILIS Change</title>
<link rel="stylesheet" type="text/css" href="/css/bootstrap.css" />
<link rel="stylesheet" type="text/css" href="/css/site.css" />
</head>
<body>
[% # PROCESS dumper.tt dump = vars %]
[% # PROCESS dumper.tt dump = errs %]
[% # PROCESS dumper.tt dump = settings %]
<div class="container">
<div class="row">
<a name="top">
<img src="/images/[% settings.report_header %]" title="Trust Logo"
border="0" align="right" alt="Logo"/>
</a>
</div>
<br clear="all" />
<!--
<table cellspacing="1" cellpadding="3" border="0" width="100%">
<tr bgcolor="#cbe0eb">
<td align="left" valign="top" class="border">
<b>Welcome to [% settings.lab_name_abbreviation %]</b>
</td>
<td align="center" class="border" valign="top" width="50%">
[% USE date(format = '%A, %d %B %Y, %T', locale = 'en_GB');
date.format %]
</td>
<td align="right" width="25%" class="border" valign="top"> </td>
</tr>
</table>
<br />
-->
<table id="main">
<tr>
<td>
<table>
<tr>
<td>
<h2 class="header">HILIS Request for Change</h2>
[% UNLESS send_success # already submitted %]
<p>
Please enter details below. All fields are required.
</p>
[% END %]
[% IF msg %]
<p class="dfv_errors">
Sorry, there is a problem with the mail server and your message was
not sent. Your details have been preserved in the form below, please
try again shortly. The error message was: "[% msg %]". Please copy
this message to <a href="mailto:[% settings.admin_contact %]">HMDS
admin</a> if the error persists. Apologies for the inconvenience.
</p>
[% ELSIF send_success %]
<p class="info">Your request has been submitted.</p>
[% END %]
<form method="post" action="[% %]" name="application"
enctype="application/x-www-form-urlencoded">
<input type="hidden" name="centre"
value="[% settings.item('_centre') %]" />
<input type="hidden" name="app_name"
value="[% app_name %]" />
<div id="registration">
<table class="indent" border="0">
<tr>
<td class="red">UserName:</td>
<td>
<input type="text" name="username" readonly="readonly" />
</td>
</tr>
<tr>
<td class="red">Reason:</td>
<td>
<select name="reason">
<option value="">-- select one --</option>
<option value="new feature">New feature</option>
<option value="modification">Modification</option>
<option value="fix error">Fix error</option>
<option value="change menu">Add/change drop-down</option>
</select>
[% errs.error_reason %]
</td>
</tr>
<tr>
<td class="red" valign="top">Details:</td>
<td>
<textarea class="form-control" name="details"
rows="3"></textarea>
[% errs.error_details %]
</td>
</tr>
<tr>
<td class="red">Status:</td>
<td>
<select name="status">
<option value="">-- select one --</option>
<option value="pending">To be discussed</option>
<option value="agreed">As agreed after discussion</option>
<option value="required">Discussion not applicable</option>
</select>
[% errs.error_status %]
</td>
</tr>
</table>
<p class="hr"></p>
</div>
[% UNLESS send_success # already submitted %]
<p class="center">
<input type="reset" class="btn btn-warning"
value="Reset All Values" />
<span style="padding: 0 5em">
<input type="submit" name="submit" class="btn btn-info"
value="Submit Request" />
</span>
</p>
[% END %]
</form>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</body>
</html>