<!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">
          &nbsp;<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">&nbsp;</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>
