{{-- <input type="button" class="btn btn-primary w-25 m-2 d-print-none" onclick="printDiv('form-body')" value="Print" /> --}}

<div class="modal fade" id="customer_survey_form_modal" tabindex="-1" aria-hidden="true">
    <div class="modal-dialog modal-xl modal-dialog-scrollable">
        <div class="modal-content">
            <div class="modal-header">
                <form class="form-floating">

                    <a class="btn btn-success form-control is-invalid" id="print_has_merge_report_link" href="#"
                        target="_blank">
                        <i class="fa fa-print" aria-hidden="true"></i>
                        {{ __('Click to download Laboratory Report') }}
                    </a>


                    <a class="btn btn-success form-control is-invalid" id="print_report_link" href="#"
                        target="_blank">
                        <i class="fa fa-print" aria-hidden="true"></i>
                        {{ __('Click to download Laboratory Report') }}
                    </a>
                    {{-- <input type="text" id="idsx" value="">
                    <input type="text" id="merge_report" value="">
                    <input type="text" id="merge_single" value="">
                    <input type="text" id="single_report" value="">
                    <input type="text" id="done_1" value=""> --}}

                </form>
            </div>

            <div class="modal-body table-responsive">

                {{-- <iframe src="/admin/customer_survey_report" id="customer_survey_report" width="100%" height="1500px" class="border-0">

        </iframe> --}}


                <div class="row d-flex justify-content-between">
                    <div class="col-3 d-flex justify-content-start">
                        <div class="row">
                            <div class="col-6">
                                <p>
                                    <span><img width="78" height="78" alt="image"
                                            src="/assets/images/Image_001.jpg" /></span>
                                </p>
                            </div>
                            <div class="col-6">
                                <p>
                                    <span><img width="79" height="78" alt="image"
                                            src="/assets/images/Image_002.jpg" /></span>
                                </p>
                            </div>
                        </div>
                    </div>
                    <div class="col-6">
                        <p class="s1 text-center fs-6">INSTITUTE OF HUMAN GENETICS</p>
                        <p class="s2 text-center fs-6">National Institutes of Health University of the Philippines
                            Manila <br> <i>“The Health Sciences Center” </i></p>
                        <p class="s3 text-center fs-6">ISO 9001:2015 Certified</p>
                    </div>
                    <div class="col-3 d-flex justify-content-end">
                        <p>
                            <span><img width="133" height="67" alt="image"
                                    src="/assets/images/Image_003.jpg" /></span>
                        </p>
                    </div>
                </div>

                <table style="border-collapse:collapse;width:100%" cellspacing="0">
                    <tr style="height:40pt">
                        {{-- <td style="width:246pt;border-top-style:solid;border-top-width:1pt;border-left-style:solid;border-left-width:1pt;border-bottom-style:solid;border-bottom-width:1pt;border-right-style:solid;border-right-width:1pt">
                <p style="text-indent: 0pt;text-align: left;"><br /></p>
                <p class="s2" style="padding-top: 9pt;padding-left: 5pt;text-indent: 0pt;text-align: left;">BIOCHEMICAL
                    GENETICS LABORATORY</p>
            </td> --}}
                        <td
                            style="width:303pt;border-top-style:solid;border-top-width:1pt;border-left-style:solid;border-left-width:1pt;border-bottom-style:solid;border-bottom-width:1pt;border-right-style:solid;border-right-width:1pt">
                            <p style="text-indent: 0pt;text-align: center;"><br /></p>
                            <p class="s3" style="padding-left: 14pt;text-indent: 0pt;text-align: center;">CUSTOMER
                                SATISFACTION SURVEY FORM</p>
                        </td>
                        {{-- <td style="width:215pt;border-top-style:solid;border-top-width:1pt;border-left-style:solid;border-left-width:1pt;border-bottom-style:solid;border-bottom-width:1pt;border-right-style:solid;border-right-width:1pt">
                <p style="text-indent: 0pt;text-align: left;"><br /></p>
                <p class="s4" style="padding-left: 5pt;text-indent: 0pt;text-align: left;">Doc Code: <b>BGL-FO-17</b>
                </p>
                <p class="s4" style="padding-left: 5pt;text-indent: 0pt;text-align: left;">Revision No. <b>00</b></p>
                <p class="s4" style="padding-left: 5pt;text-indent: 0pt;text-align: left;">Effectivity Date: <b>28 June 2021</b></p>
            </td> --}}
                    </tr>
                </table>
                <div class="col-lg-12">
                    <h6 style="text-indent: 0pt;text-align: left;">Your satisfaction regarding the services provided by
                        the laboratory is an important indicator for the quality of
                        our work. We therefore would like to ask you to please take a few minutes to fill in our short
                        survey and help us
                        improve our services.</h6>
                </div>
                <form method="POST" action="{{ route('patient.groups.customer_survey_store') }}" id="cus_survey_form"
                    enctype="multipart/form-data">
                    @csrf
                    <div class="row m-2">
                        <div class="col-lg-12">
                            <div class="form-group">
                                <div class="input-group">
                                    <div class="input-group-prepend">
                                        <span class="input-group-text" id="basic-addon1">
                                            <i class="fas"><span style="color:red">*</span>
                                                {{ __('Survey Date') }}</i>
                                        </span>
                                    </div>
                                    <input autocomplete="off" max="2025-08-03" type="date"
                                        class="form-control dob_datepicker" placeholder="{{ __('Date of birth') }}"
                                        name="survey_date" required value="{{ date('Y-m-d') }}" readonly>
                                </div>
                            </div>
                        </div>
                        <div class="col-lg-6">
                            <div class="form-group">
                                <label for="">{{ __('Contact Details') }}</label>
                                <div class="input-group ">
                                    <input type="text" class="form-control"
                                        placeholder="{{ __('Contact Details') }}" name="contact_details"
                                        value="">
                                </div>
                            </div>
                        </div>
                        <div class="col-lg-6">
                            <div class="form-group">
                                <label for="">{{ __('Region') }}</label>
                                <div class="input-group ">
                                    <select class="form-control" name="region" placeholder="{{ __('Region') }}"
                                        id="region_name">
                                        <option value="" disabled selected>{{ __('Region') }}</option>
                                        @if (isset($regions))
                                            @foreach ($regions as $region)
                                                <option value="{{ $region->id }}" selected>{{ $region->name }}
                                                </option>
                                            @endforeach
                                        @else
                                            {{-- @foreach ($regions as $regionx)
                            <option value="{{ $regionx->id }}">{{ $regionx->name }}</option>
                            @endforeach --}}
                                        @endif
                                    </select>
                                </div>
                            </div>
                        </div>
                        <div class="col-lg-6">
                            <div class="form-group">
                                <label for="">{{ __('Gender') }}</label>
                                <div class="input-group">
                                    {{-- <select readonly class="form-control" name="gender" placeholder="{{__('Gender')}}" id="gender">
                            <option value="" disabled selected>{{__('Gender')}}</option>
                            <option value="male" @if (isset($patients) && $patients['gender'] == 'male') selected @elseif(isset($patients)&&$patients['gender']=='Male' ) selected @elseif(old('gender')=='male' ) selected @endif>{{__('Male')}}</option>
                            <option value="female" @if (isset($patients) && $patients['gender'] == 'female') selected @elseif(isset($patients)&&$patients['gender']=='Female' ) selected @elseif(old('gender')=='female' ) selected @endif>{{__('Female')}}</option>
                            <option value="ambiguous" @if (isset($patients) && $patients['gender'] == 'ambiguous') selected @elseif(isset($patients)&&$patients['gender']=='Ambiguous' ) selected @elseif(old('gender')=='ambiguous' ) selected @endif>{{__('Ambiguous')}}</option>

                        </select> --}}
                                    <input type="text" class="form-control" placeholder="Gender" name="gender"
                                        id="gender" readonly>
                                </div>
                            </div>
                        </div>

                        <div class="col-lg-6">
                            <div class="form-group">
                                <label for="">{{ __('Client Type') }}</label>
                                <div class="input-group ">
                                    <select name="client_type" class="form-control">
                                        <option disabled>--Select Client Type--</option>
                                        <option value="NSC/NSF">{{ __('NSC/NSF') }}</option>
                                        <option value="Pay(Private)">{{ __('Pay(Private)') }}</option>
                                        <option value="Pay(Public)">{{ __('Pay(Public)') }}</option>
                                        <option value="Research(Internal/External)">
                                            {{ __('Research(Internal/External)') }}</option>
                                    </select>
                                </div>
                            </div>
                        </div>
                        <div class="col-lg-3">
                            <div class="form-group">
                                <label for="branch_id">{{ __('Laboratory') }}</label>
                                <select readonly name="branch_id[]" class="form-control select2">
                                    <option disabled value="">-- SELECT LABORATORY --</option>
                                    @if (isset($laboratories))
                                        {{-- @foreach ($groups->branches as $lab)
                        <option value="{{ $lab->id }}" selected>{{ $lab->name }}</option>
                        @endforeach --}}
                                        @foreach ($laboratories as $laboratory)
                                            <option value="{{ $laboratory->id }}">{{ $laboratory->name }}</option>
                                        @endforeach
                                    @else
                                        {{-- @foreach ($laboratories as $laboratory)
                        <option value="{{ $laboratory->id }}">{{ $laboratory->name }}</option>
                        @endforeach --}}
                                    @endif
                                </select>
                            </div>
                        </div>
                        <div class="col-lg-9">
                            {{-- @if (isset($groups))
                @php
                $selected_tests = [];
                foreach ($groups['tests'] as $tests){
                foreach($tests->tests_c as $test){
                $selected_tests[] = $test['id'];
                }
                }
                @endphp
                @endif --}}
                            <div class="form-group">
                                <label for="filter_test">{{ __('Test/s') }}</label>
                                <select readonly name="test[]" id="filter_test" class="form-control select2">
                                    {{-- @if (isset($groups))

                        @foreach ($tests_x as $test_x) --}}
                                    {{-- <option value="{{ $test->id }}" {{ (isset($selected_tests) && in_array($test->id, $selected_tests)) ? 'selected' : '' }}>{{ $test->name }}</option> --}}
                                    {{-- <option value="{{$test_x->id}}" {{ in_array($test_x->id, $selected_tests) ? 'selected' : '' }}>{{ $test_x->name }}</option>
                        @endforeach
                        @endif --}}
                                </select>
                            </div>
                        </div>
                    </div>
                    <div class="col-lg-12">
                        <div class="card">
                            <div class="card-header">
                                <h3 class="card-title"><b>{{ __('HOW WELL DID WE SERVE YOU?') }}</b></h3>
                            </div>
                            <div class="card-body m-0 p-0">
                                <div class="col-lg-12 table-responsive">
                                    <table class="table table-striped table-bordered">
                                        <thead>
                                        </thead>
                                        <tbody>
                                            <tr>
                                                <td>Promptness of Service (*M to F working days)</td>
                                                <td><input type="radio" name="promptness_of_service"
                                                        value="≤7 working days">≤7 working days</td>
                                                <td><input type="radio" name="promptness_of_service"
                                                        value="8-10 working days"> 8-10 working days</td>
                                                <td><input type="radio" name="promptness_of_service"
                                                        value="11-15 working days"> 11-15 working days</td>
                                                <td><input type="radio" name="promptness_of_service"
                                                        value="15-30 working days"> 15-30 working days</td>
                                                <td><input type="radio" name="promptness_of_service"
                                                        value=">30 working days"> >30 working days</td>
                                            </tr>
                                            <tr>
                                                <td>Attitude of Attending Personnel</td>
                                                <td><input type="radio" name="attitude_of_personnel"
                                                        value="Inconsiderate"> Inconsiderate</td>
                                                <td><input type="radio" name="attitude_of_personnel"
                                                        value="Unprofessional"> Unprofessional</td>
                                                <td><input type="radio" name="attitude_of_personnel"
                                                        value="Knowledgeable"> Knowledgeable</td>
                                                <td><input type="radio" name="attitude_of_personnel"
                                                        value="Efficient"> Efficient</td>
                                                <td><input type="radio" name="attitude_of_personnel"
                                                        value="Well-mannered"> Well-mannered</td>
                                            </tr>
                                        <tbody>
                                    </table>
                                    <table class="table table-striped table-bordered">
                                        <thead>
                                            <tr>
                                                <th>Question</th>
                                                <th>Poor</th>
                                                <th>Fair</th>
                                                <th>Satisfactory</th>
                                                <th>Very Satisfactory</th>
                                                <th>Excellent</th>
                                            </tr>
                                        </thead>
                                        <tbody>
                                            <tr>
                                                <td>Released results are accurate with no errors in patient data</td>
                                                <td><input type="radio" name="accurate_results" value="Poor">
                                                </td>
                                                <td><input type="radio" name="accurate_results" value="Fair">
                                                </td>
                                                <td><input type="radio" name="accurate_results"
                                                        value="Satisfactory"></td>
                                                <td><input type="radio" name="accurate_results"
                                                        value="Very Satisfactory"></td>
                                                <td><input type="radio" name="accurate_results" value="Excellent">
                                                </td>
                                            </tr>
                                            <tr>
                                                <td>Overall assessment of the attitude of the attending staff</td>
                                                <td><input type="radio" name="overall_attitude" value="Poor">
                                                </td>
                                                <td><input type="radio" name="overall_attitude" value="Fair">
                                                </td>
                                                <td><input type="radio" name="overall_attitude"
                                                        value="Satisfactory"></td>
                                                <td><input type="radio" name="overall_attitude"
                                                        value="Very Satisfactory"></td>
                                                <td><input type="radio" name="overall_attitude" value="Excellent">
                                                </td>
                                            </tr>
                                            <tr>
                                                <td>Overall quality of service</td>
                                                <td><input type="radio" name="overall_quality" value="Poor"></td>
                                                <td><input type="radio" name="overall_quality" value="Fair"></td>
                                                <td><input type="radio" name="overall_quality"
                                                        value="Satisfactory"></td>
                                                <td><input type="radio" name="overall_quality"
                                                        value="Very Satisfactory"></td>
                                                <td><input type="radio" name="overall_quality" value="Excellent">
                                                </td>
                                            </tr>
                                        <tbody>
                                    </table>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="col-lg-12">
                        <div class="card">
                            <div class="card-header">
                                <h5 class="card-title">
                                    {{ __('Complaints/ Comments/ Suggestions to improve our services, if any:') }}</h5>
                            </div>
                            <div class="card-body m-1 p-1">
                                <div class="form-group" id="notes">
                                    <textarea name="complaint_comment" id="complaint_comment" rows="3" class="form-control"></textarea>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="col-lg-12">
                        <div class="card">
                            <div class="card-header">
                                <h3 class="card-title"><b>{{ __('Data Privacy Policy Disclosure') }}</b></h3><br>
                                <p>In submitting this form, I agree to my details being used for the purposes of
                                    surveying customer satisfaction. The information will only be accessed by necessary
                                    university staff. I understand my data will be held securely and will not be
                                    distributed to third parties. I have a right to change or access my information. I
                                    understand that when this information is no longer required for this purpose,
                                    official university procedure will be followed to dispose of my data.</p>
                            </div>
                            <div class="card-body ">
                                <div class="form-group" id="notes">
                                    <label for="agree">Do you agree to the above terms?</label>
                                    <div class="form-check">

                                        <div class="col-lg-12 ">
                                            <input class="form-check-input " style="margin-left: 10px" type="radio"
                                                name="agree_term" id="agree_yes" value="1" required>
                                            <label class="form-check-label" style="margin-left: 30px"
                                                for="agree_yes">Agree</label>

                                            <input class="form-check-input" style="margin-left: 10px" type="radio"
                                                name="agree_term" id="agree_no" value="0" required>
                                            <label class="form-check-label" style="margin-left: 30px"
                                                for="agree_no">Disagree</label>
                                        </div>

                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                    <button type="submit" class="btn btn-primary w-25 mt-3 ml-3"
                        id="cus_sur_modal_sub">{{ __('Save') }}</button>
                </form>
            </div>
            <!-- /.modal-content -->
        </div>
        <!-- /.modal-dialog -->
    </div>
    <!-- /.card-body -->
</div>