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| 08.05.2008 at 05:37AM PDT, ID: 23621933 |
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<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office">
<head>
<title>Hard of Hearing Form</title>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<style type="text/css">
<!--
.style2 {
FONT-SIZE: x-small;
font-size: x-small;
font-family: Verdana;
}
.style3 {font-family: Verdana, Arial, Helvetica, sans-serif}
th
{ color: #000000; font-family: Tahoma, Verdana; font-size: 11px; }
.newStyle1 {
font-family: Verdana;
FONT-SIZE: x-small;
background-color: #0099CC;
}
.newStyle2 {
color: #D9ECFF;
background-color: #FFFFFF;
}
.newStyle1Copy {
font-family: Verdana;
FONT-SIZE: x-small;
background-color: #CAE4FF;
}
-->
</style>
<script type="text/javascript">
<!--
/*********************************************************************
Original Script By
Patrick Fairfield (a.k.a fritz_the_blank)
Fairfield Consulting
========================================================
Edited by Jay Solomon
jaysolomon *AT* pclnet *DOT* net
edited by Dariusz Tybor
*********************************************************************/
var strAlertMsg = ""
var focusField = ""
//============================================================
//validate Date
function isDate(theForm,strFieldName,strMsg){
var objFormField = theForm.elements[strFieldName];
strDate = objFormField.value;
if(strDate.length>0){
var dateregex=/^[ ]*[0]?(\d{1,2})\/(\d{1,2})\/(\d{4,})[ ]*$/;
var match=strDate.match(dateregex);
if (match){
var tmpdate=new Date(match[3],parseInt(match[1],10)-1,match[2]);
if (tmpdate.getDate()==parseInt(match[2],10) && tmpdate.getFullYear()==parseInt(match[3],10) && (tmpdate.getMonth()+1)==parseInt(match[1],10)){
return true;
}
}
strAlertMsg += "- "+ strMsg +" is Required.\nExample: 01/01/2003\n";
if(!focusField) focusField =""+ strFieldName +"";
return false;
}
else{
return true;
}
}
//========================================================================
//Validate Us Phone. Ex. (999) 999-9999 or (999)999-9999
function isPhone(theForm,strFieldName,strMsg) {
var objFormField = theForm.elements[strFieldName];
var strValue = objFormField.value;
var objRegExp = /^\([1-9]\d{2}\)\s?\d{3}\-\d{4}$/;
if(!objRegExp.test(strValue)){
strAlertMsg += "- "+ strMsg +" is Required.\n Example:\n(999)999-9999 or (999) 999-9999\n";
if(!focusField) focusField=""+ strFieldName +"";
return false;
}
return true;
}
//========================================================================
//Validate US zip code in 5 digit format or zip+4 format. 99999 or 99999-9999
function isZipCode(theForm,strFieldName,strMsg) {
var objFormField = theForm.elements[strFieldName];
var strValue = objFormField.value;
var objRegExp = /(^\d{5}$)|(^\d{5}-\d{4}$)/;
if(!objRegExp.test(strValue)){
strAlertMsg += "- "+ strMsg +" is Required.\n";
if(!focusField) focusField =""+ strFieldName +"";
return false;
}
return true;
}
//==========================================================================
//Validate the Select
function hasSelection(theForm,strFieldName,strMsg) {
var objFormField = theForm.elements[strFieldName];
if(objFormField.selectedIndex ==0) {
strAlertMsg += "- "+ strMsg +" is Required.\n";
return false;
}
return true;
}
//========================================================================
//Validate Check Box
function isChecked(theForm,strFieldName,strMsg) {
var objFormField= theForm.elements[strFieldName];
var strValue= objFormField.checked;
if (!strValue) {
//alert("The \""+ strMsg +"\" box is checked!")
//} else {
strAlertMsg += "- "+ strMsg +" is Required.\n";
if(!focusField) focusField =""+ strFieldName +"";
return false;
}
return true;
}
//========================================================================
//Validate Text Box
function isEmpty(theForm,strFieldName,strMsg){
var objFormField = theForm.elements[strFieldName];
var strValue = objFormField.value;
strValue = strValue.split(" ").join("")
if(strValue.length<1){
strAlertMsg += "- "+ strMsg +" is Required.\n";
if(!focusField) focusField =""+ strFieldName +"";
return false;
}
return true;
}
//========================================================================
//Validate Email
function isEmail(theForm,strFieldName,strMsg){
var objFormField = theForm.elements[strFieldName]
var strEmail = objFormField.value;
var bolValid = true;
if(strEmail.length < 7){
bolValid = false;
}
if(strEmail.lastIndexOf(" ") >0){
bolValid = false;
}
var intLastDot = strEmail.lastIndexOf(".")
if(intLastDot == -1 || strEmail.length - intLastDot >4){
bolValid = false;
}
var intAt = strEmail.lastIndexOf("@")
if(intAt == -1 || strEmail.length - intAt < 5){
bolValid = false;
}
if(!bolValid){
strAlertMsg += "- "+ strMsg +" is Required.\n";
if(!focusField) focusField =""+ strFieldName +"";
}
return bolValid;
}
//========================================================================
//Validate Radio Button
function checkRadioControl(theForm,strFieldName,strMsg){
var objFormField = theForm.elements[strFieldName]
intControlLength = objFormField.length
bolSelected = false;
for (i=0;i<intControlLength;i++){
if(objFormField[i].checked){
objFormField[0].style.backgroundColor = "white";
bolSelected = true;
break;
}
}
if(! bolSelected){
if(!focusField) focusField =""+ objFormField[0].id +"";
strAlertMsg += "- "+ strMsg +" is Required.\n";
objFormField[0].style.backgroundColor = "yellow";
return false;
}
return true;
}
//========================================================================
//Compare the Fields
function compareFields(theForm,strFieldName1,strFieldName2,strMsg){
var objFormField1= theForm.elements[strFieldName1];
var objFormField2= theForm.elements[strFieldName2];
var strValue1= objFormField1.value;
var strValue2= objFormField2.value;
if(strValue1 != strValue2){
strAlertMsg +="The "+ strMsg +" fields do not match, please try again.\n";
if(!focusField) focusField =""+ strFieldName1 +"";
return false;
}
return true;
}
//========================================================================
//Format Phone Number 9999999999 = (999)999-9999
//Call the function like so onKeyPress="javascript:formatPhone(this);
function formatPhone(objFormField){
intFieldLength = objFormField.value.length;
if(intFieldLength == 3){
objFormField.value = "(" + objFormField.value + ") ";
return false;
}
if(intFieldLength >= 9 && intFieldLength <= 10){
objFormField.value = objFormField.value + "-";
return false;
}
}
//========================================================================
//End .js File
//Begin Page Validation
function validateForm(theForm){
strAlertMsg = ""
focusField = ""
isEmpty(theForm,'Customer_Name','Name')
isEmpty(theForm,'email','Email')
isEmpty(theForm,'dDate','Date')
checkRadioControl(theForm,'radio1','Radio Button 1')
isEmpty(theForm,'tech-used','textbox 1')
checkRadioControl(theForm,'radio3','Radio Button 2')
checkRadioControl(theForm,'radio4','Radio Button 3')
checkRadioControl(theForm,'radio5','Radio Button 4')
checkRadioControl(theForm,'radio6','Radio Button 5')
checkRadioControl(theForm,'radio7','Radio Button 6')
isEmpty(theForm,'PhoneB0','textbox 3')
isEmpty(theForm,'PhoneB','textbox 2')
checkRadioControl(theForm,'radio10','Radio Button 7')
checkRadioControl(theForm,'radio11','Radio Button 8')
checkRadioControl(theForm,'radio12','Radio Button 9')
if(strAlertMsg !=""){
alert("Please correct the following errors:\n____________________________\n\n" + strAlertMsg);
eval("theForm." + focusField + ".focus()");
//alert(focusField);
theForm[focusField].focus();
return false;
}
return true;
}
//-->
</script>
<script>
function setDate(){
aDate = new Date()
toDay = (aDate.getMonth()+1)+"/"+aDate.getDate()+"/"+aDate.getFullYear();
document.forms[0].dDate.value=toDay;
}
function Focus() {
document.getElementById('Customer_Name').focus();
}
function Load()
{
setDate();
Focus();
}
</script>
</head>
<body class="sub" onLoad="Load();">
<form id="form1" action="/508/AT-Wizard/Hard-of-Hearing-Form-proc.asp" method="post" onsubmit="return validateForm(this);">
<table border="0" cellspacing="2" cellpadding="4" style="width: 800">
<tr style="vertical-align: top">
<td valign="top" nowrap="nowrap" style="width: 722px; height: 31px;">
<table cellSpacing="0" cellPadding="0" align="left" border="0" style="width: 713px">
<tr>
<th style="FONT-SIZE: small; COLOR: white" noWrap bgColor="#4682b4" tabindex="0">
Hard of Hearing Form<img height="1" src="pixel.gif" width="10" border="0" /></th>
<td>
<img height="21" src="formtab_r.gif" width="10" border="0" /></td>
<td width="100%" background="line_t.gif" class="newStyle1"> </td>
</tr>
</table>
</td>
</tr>
<tr style="vertical-align: top">
<td valign="top" nowrap="nowrap" style="width: 722px">
<p class="style2">
<span class="style2">
<label id="lblCustome_Name" for="Customer_Name" class="style2">Name</label></span>
<input type="text" id="Customer_Name" name="Customer_Name" class="newStyle1Copy" tabindex="0" />
<br />
<br />
<label id="lblemail" for="email" class="style2">Email </label>
<input type="text" name="email" id="email" class="newStyle1Copy" tabindex="0" />
<br />
<br />
<label id="lbldDate" for="dDate" class="style2">Date (read only)</label>
<input type="text" name="dDate" id="dDate" class="newStyle1Copy" tabindex="0" readonly="readonly" /><br />
<p class="style2">
<FIELDSET class="style2">
<LEGEND class="style2"> 1. <span>Are you currently using any assistive
technology?</span></LEGEND>
<input type="radio" name="radio1" value="Yes" id="radio1y0" class="style2" tabindex="0" /><span class="style2">Yes
</span>
<label>
<input type="radio" name="radio1" value="No" id="radio1n0" class="style2" /><span class="style2">No</span></label>
</FIELDSET><p class="style2">
<FIELDSET>
<legend class="style2">2. <span>If yes to the above question, please
list all assistive technology being used.</span></legend>
<textarea name="tech-used" id="tech-used" rows="5" class="newStyle1Copy" style="width: 373px" tabindex="0" cols="20"></textarea>
</FIELDSET><p class="style2">
<FIELDSET class="style2">
<LEGEND class="style2"> 3. Do you use hearing aides?</LEGEND>
<input type="radio" name="radio3" value="Yes" id="radio1y" class="style2" tabindex="0" /><span class="style2">Yes
</span>
<label><input type="radio" name="radio3" value="No" id="radio1n" class="style2" /><span class="style2">No</span></label>
</FIELDSET><span class="style2"> </span><br>
<FIELDSET style="height: 38px">
<legend class="style2">4. Are your hearing aides T-coil compatible?</legend>
<span class="style2">
<input type="radio" name="radio4" value="Yes" id="radio2n1" class="style2" />Yes
<input type="radio" name="radio4" value="No" id="radio2n" class="style2" />No
<input type="radio" name="radio4" value="Not Sure" id="radio2n0" class="style2" />Not
Sure</span><br /></FIELDSET>
<br />
<span class="style2">
<fieldset class="style2">
<legend>5. Are they in the ear or behind the ear hearing aides?</legend>
<label id="Label4" for="radio8"><input type="radio" name="radio5" value="Behind the ear" id="radio8y" /></label>Behind
the ear
<input type="radio" name="radio5" value="In the ear" id="radio8n" />In the ear</fieldset></span><br>
<span class="style3">
<fieldset class="style2">
<legend>6. Do you use hearing aides in one or both ears? </legend>
<span class="style3">
<label id="Label5" for="radio8">
<input type="radio" name="radio6" value="One" id="radio8y0" /></label>One
<input type="radio" name="radio6" value="Both" id="radio8n0" />Both</span></fieldset></span><br />
</span>
<span class="style3">
<FIELDSET class="style2">
<legend>7. Do you need amplification for your phone?</legend>
<input type="radio" name="radio7" value="Yes" id="radio3y" tabindex="0" />Yes
<input type="radio" name="radio7" value="No" id="radio3n" tabindex="0" />No
</FIELDSET><br />
</span>
<FIELDSET>
<legend class="style2">8. What brand and model of cell phone do you use?</legend>
<textarea name="PhoneB0" id="PhoneB0" rows="5" class="newStyle1Copy" style="width: 373px" tabindex="0" cols="20"></textarea></FIELDSET><span class="style3"><br />
</span>
<FIELDSET>
<legend class="style2">9. What brand and model of phone do you
use?</legend>
<textarea name="PhoneB" id="PhoneB" rows="5" class="newStyle1Copy" style="width: 373px" tabindex="0"></textarea>
</FIELDSET>
<span class="style3">
</span><br>
<fieldset>
<span class="style2">
<legend>10. Do you need amplification for your computer?</legend>
<label id="lblFname" for="radio5">
<input type="radio" name="radio10" value="Yes" id="radio5y" class="style2" /></label></span><label id="Label1" for="radio5"><span class="style2">Yes</span></label><span class="style3">
<label>
<input name="radio10" type="radio" id="radio5n" value="No" class="style2" /></label></span><label><span class="style2">No</span></label><span class="style3">
</span></fieldset>
<p class="style2"><span class="style3">
</p>
<fieldset class="style2">
<legend>11. Do you need amplification to an cell phone?</legend>
<label id="Label2" for="radio6"><input type="radio" name="radio11" value="Yes" id="radio6y" />Yes</label>
<label>
<span class="style3">
<input type="radio" name="radio11" value="No" id="radio6n" /></span>No</label></fieldset>
</span>
<p class="style2"><span class="style3">
</p>
<fieldset class="style2">
<legend>12. Do you use Voice Carry Over (VCO) for relay calls?</legend>
<label id="Label3" for="radio7"><input type="radio" name="radio12" value="Yes" id="radio7y" />Yes
<input type="radio" name="radio12" value="No" id="radio7n" />No</fieldset>
</span>
<p class="style2"><span class="style3">
</p>
</SPAN><span class="style3"></span><p class="style2">
<span class="style3">
</span> </p>
</td>
</tr>
<tr style="vertical-align: top">
<td style="width: 722px">
<input type="submit" id="btnSubmit" name="btnSubmit" value="Submit" />
<input type="reset" id="btnReset" name="btnReset" value="Reset" />
</td>
</tr>
</table>
</form>
</body>
</html>
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