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BC CDC PHSA Lab Requisition for Bacteriology and Mycology Page 2 counter no time HTML

HTML icon Bacteriology & Mycology Requisition Isolates for ID count no time.html — HTML, 24 kB (25398 bytes)

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<html>
<head>
<title>Baceriology & Mycology Requisition Isolates for ID</title>

	<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />

<style type="text/css" media="print">
 .DoNotPrint {
	 display: none;
 }
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	 border : 0px;
	 background: transparent;
	 scrollbar-3dlight-color: transparent;
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	 background: transparent;
	 overflow: hidden;
 }
 </style>

<script language="javascript" type="text/javascript">
		/****************************
		startup functions 
		****************************/
		function startUp()
		{			
			// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
			var strLoc = window.location.href.toLowerCase();
			if(strLoc.indexOf("https") == -1)
			{
				//page1
				var src = document.getElementById('BGImage').src;				
				document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');
				
			}
			setDocumentTitle('Baceriology & Mycology Requisition Isolates for ID',document.getElementById('Surname').value);
		}
		
		function setDocumentTitle(Title,Surname)
		{
			// set document title
			document.title = Title + ' - ' + Surname;					
							
		}
		

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			submission();
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			setTimeout('document.FormName.submit()',1000);			
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		{
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			else
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			if (charCode != 9)
			{
				changeValue(x);
				return false;
			}
		}
		</script>


<script type="text/javascript" language="javascript">
function checkGender(){
	 if (document.getElementById('PatientGender').value == 'M'){
	 document.getElementById('Male').value = 'X';
	 }else if (document.getElementById('PatientGender').value == 'F'){
	 document.getElementById('Female').value = 'X';
	}
 }
</script>

<!-- scripts to confirm closing of window if haven't saved yet -->
	<script language="javascript">
		//keypress events trigger dirty flag
		var needToConfirm = false;
		document.onkeyup=setDirtyFlag;
function setDirtyFlag()
		{
		needToConfirm = true;
		}
function releaseDirtyFlag()
		{
		needToConfirm = false; //Call this function if doesn't requires an alert.
		//this could be called when save button is clicked
		}
		window.onbeforeunload = confirmExit;
function confirmExit()
		{
		if (needToConfirm)
		{
		return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
		}
		}
</script>

<!-----------------script for current time--------->
<script language="javascript">

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function StartClock12() {
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Cur12Hour = Time12.getHours();
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window.status = The12Time;
setTimeout('StartClock12()',1000);
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<script language="javascript" type="text/javascript">
function onLoad(){
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}
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</head>

<body onload="checkGender();startUp();onLoad()" onMouseDown="showButtons();">

<form method="post" action="" name="FormName" id="FormName" >

<div id="page1" style="position:relative; left:0px; top:0px; width:750px;" class="pagebreak">

<img id='BGImage' src="${oscar_image_path}BAMReq-2.png" width="750px" >

	<input type="hidden" name="counter" id="counter">


<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:154px; top:123px; width:137px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=hinc>


<span style="position: absolute; left:25px; top:133px; font-size:8px; font-family: Arial; ">(or out of province Health Number</span>


<span style="position: absolute; left:25px; top:142px; font-size:8px; font-family: Arial; ">and Province)</span>


<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:321px; top:123px; width:71px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=dob>


<input name="GenderUnk" id="GenderUnk" type="text" style="position:absolute; left:507px; top:132px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Surname" id="Surname" type="text" class="noborder" style="position:absolute; left:113px; top:153px; width:179px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=patient_nameL>


<span style="position: absolute; left:296px; top:152px; font-size:10px; font-family: Arial; ">Patient First and</span>


<span style="position: absolute; left:296px; top:163px; font-size:10px; font-family: Arial; ">Middle Name</span>


<input name="FirstName" id="FirstName" type="text" class="noborder" style="position:absolute; left:380px; top:153px; width:176px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=patient_nameF>


<input name="StreetAddress" id="StreetAddress" type="text" class="noborder" style="position:absolute; left:71px; top:182px; width:220px; height:27px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=address_street_number_and_name>


<input name="City" id="City" type="text" class="noborder" style="position:absolute; left:321px; top:182px; width:147px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=city>


<span style="position: absolute; left:473px; top:182px; font-size:10px; font-family: Arial; ">P.C.</span>


<input name="PostalCode" id="PostalCode" type="text" class="noborder" style="position:absolute; left:493px; top:182px; width:62px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=postal>


<span style="position: absolute; left:124px; top:245px; font-size:8px; font-family: Arial; ">(& MSC#)</span>


<input name="DoctorName" id="DoctorName" type="text" class="noborder" style="position:absolute; left:159px; top:241px; width:95px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=provider_name_first_init>


<input name="MSPNumber" id="MSPNumber" type="text" class="noborder" style="position:absolute; left:254px; top:241px; width:40px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=doctor_ohip_no>


<textarea name="ClinicAddress" id="ClinicAddress" class="noborder" style="position:absolute; left:26px; top:263px; width:265px; height:36px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_addressLineFull></textarea>


<input name="NoCopy" id="NoCopy" type="text" style="position:absolute; left:26px; top:301px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"> 


<span style="position: absolute; left:40px; top:301px; font-size:8px; font-family: Arial; ">I do not require a copy of this report</span>


<textarea name="ClinicAddress2" id="ClinicAddress2" class="noborder" style="position:absolute; left:24px; top:335px; width:267px; height:34px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_addressLineFull></textarea>


<input name="PHSAClientNo" id="PHSAClientNo" type="text" class="noborder" style="position:absolute; left:84px; top:369px; width:206px; height:13px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="">


<textarea name="AdditionalCopy1" id="AdditionalCopy1" class="noborder" style="position:absolute; left:308px; top:255px; width:244px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>


<textarea name="AdditionalCopy2" id="AdditionalCopy2" class="noborder" style="position:absolute; left:308px; top:297px; width:244px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>


<textarea name="AdditionalCopy3" id="AdditionalCopy3" class="noborder" style="position:absolute; left:308px; top:339px; width:244px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>


<input name="SampleRefNum" id="SampleRefNum" type="text" class="noborder" style="position:absolute; left:563px; top:297px; width:163px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">


<input name="Date" id="Date" type="text" class="noborder" style="position:absolute; left:563px; top:330px; width:162px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=today>


<input name="Time" id="Time" type="text" class="noborder" style="position:absolute; left:563px; top:363px; width:162px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">


<input name="BactforID" id="BactforID" type="text" style="position:absolute; left:28px; top:420px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="FungforID" id="FungforID" type="text" style="position:absolute; left:28px; top:450px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Source" id="Source" type="text" class="noborder" style="position:absolute; left:65px; top:484px; width:235px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="MediaIsolate" id="MediaIsolate" type="text" class="noborder" style="position:absolute; left:150px; top:514px; width:150px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<textarea name="DirectSmear" id="DirectSmear" class="noborder" style="position:absolute; left:25px; top:569px; width:360px; height:55px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" ></textarea>


<textarea name="Microscopic" id="Microscopic" class="noborder" style="position:absolute; left:25px; top:641px; width:360px; height:55px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" ></textarea>


<textarea name="Morphology" id="Morphology" class="noborder" style="position:absolute; left:25px; top:713px; width:360px; height:55px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" ></textarea>


<input name="O2" id="O2" type="text" style="position:absolute; left:390px; top:489px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="CO2" id="CO2" type="text" style="position:absolute; left:443px; top:489px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Anaerobic" id="Anaerobic" type="text" style="position:absolute; left:502px; top:489px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Microaerophilic" id="Microaerophilic" type="text" style="position:absolute; left:577px; top:489px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="CatPos" id="CatPos" type="text" style="position:absolute; left:443px; top:515px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="CatNeg" id="CatNeg" type="text" style="position:absolute; left:502px; top:515px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="OxPos" id="OxPos" type="text" style="position:absolute; left:443px; top:541px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="OxNeg" id="OxNeg" type="text" style="position:absolute; left:502px; top:541px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="MotileYes" id="MotileYes" type="text" style="position:absolute; left:443px; top:567px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="MotileNo" id="MotileNo" type="text" style="position:absolute; left:502px; top:567px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="MacConkeyYes" id="MacConkeyYes" type="text" style="position:absolute; left:502px; top:593px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="MacConkeyNo" id="MacConkeyNo" type="text" style="position:absolute; left:556px; top:593px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="OtherBact" id="OtherBact" type="text" class="noborder" style="position:absolute; left:421px; top:610px; width:235px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="37" id="37" type="text" style="position:absolute; left:443px; top:687px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="40" id="40" type="text" style="position:absolute; left:502px; top:687px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="GermTubePos" id="GermTubePos" type="text" style="position:absolute; left:443px; top:713px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="GermTubeNeg" id="GermTubeNeg" type="text" style="position:absolute; left:502px; top:713px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="OtherMyc" id="OtherMyc" type="text" class="noborder" style="position:absolute; left:421px; top:730px; width:235px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="CommercialIDSys" id="CommercialIDSys" type="text" class="noborder" style="position:absolute; left:140px; top:775px; width:470px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="SuspectedID" id="SuspectedID" type="text" class="noborder" style="position:absolute; left:140px; top:800px; width:470px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="ExamRequested" id="ExamRequested" type="text" class="noborder" style="position:absolute; left:140px; top:818px; width:470px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="SupervisorApproval" id="SupervisorApproval" type="text" class="noborder" style="position:absolute; left:118px; top:855px; width:210px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="DateApproval" id="DateApproval" type="text" class="noborder" style="position:absolute; left:118px; top:880px; width:210px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="ContactEmail" id="ContactEmail" type="text" class="noborder" style="position:absolute; left:475px; top:855px; width:210px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">


<input name="ContactTelephone" id="ContactTelephone" type="text" class="noborder" style="position:absolute; left:475px; top:880px; width:210px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;  text-decoration:underline;" value="">





















<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Male" id="Male" type="text" class="noborder" style="position:absolute; left: 448px; top: 132px;  width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Female" id="Female" type="text" class="noborder" style="position:absolute; left: 479px; top: 132px;  width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">



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		<table>
		<tr><td>
		<input type="hidden" id="newForm" name="newForm" value="True" />				
		Subject: <input name="subject" size="40" type="text"> 
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="button" onclick="releaseDirtyFlag();submission()">
		<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
		<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> 			
		<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="printSubmit()">
		</td></tr>
		</table>
</div>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
</form>

</body>
</html>

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