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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" >
<head><title>

</title>


    <script src="http://ajax.googleapis.com/ajax/libs/jquery/1.6.4/jquery.min.js" type="text/javascript"></script>
    <script src="https://ajax.googleapis.com/ajax/libs/jqueryui/1.8.16/jquery-ui.js" type="text/javascript"></script>


    <link href="../niceforms/niceforms-default.css" rel="stylesheet" type="text/css" />
    <script src="../niceforms/niceforms.js" type="text/javascript"></script>

    <link href="../jquery-ui-1.8.16.custom.css" rel="stylesheet" type="text/css" />


    <script>
        jQuery(function($) {
        //$("#occurrence_dateTextBox").mask("99/99/9999");
        //$("#report_dateTextBox").mask("99/99/9999");
        $("#occurrence_dateTextBox").datepicker();
        $("#report_dateTextBox").datepicker();
        //$(".datepicker").datepicker();

    });
    $(function() {
        $.get('../file.txt', function(data) {
            var output = data.split('\n'),
            tmp = '';
            for (i = 0; i < output.length; i++) {
                tmp += '<option value=' + output[i] + '>' + output[i] + '</option>';
            }
            $('#lstProblems').html(tmp);

        });
    });

    </script>
</head>
<body><div id="container">
    <form name="form1" method="post" action="webform1.aspx" id="form1" class="niceform">
<div>
<input type="hidden" name="__EVENTTARGET" id="__EVENTTARGET" value="" />
<input type="hidden" name="__EVENTARGUMENT" id="__EVENTARGUMENT" value="" />
<input type="hidden" name="__LASTFOCUS" id="__LASTFOCUS" value="" />
<input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwUKLTU2Mzg4ODA5NmQYAQUeX19Db250cm9sc1JlcXVpcmVQb3N0QmFja0tleV9fFgIFC2xzdFByb2JsZW1zBQlDaGVja0JveDFL9/DxXpCA+Wgihd2P093yq+8YZw==" />
</div>

<script type="text/javascript">
//<![CDATA[
var theForm = document.forms['form1'];
if (!theForm) {
    theForm = document.form1;
}
function __doPostBack(eventTarget, eventArgument) {
    if (!theForm.onsubmit || (theForm.onsubmit() != false)) {
        theForm.__EVENTTARGET.value = eventTarget;
        theForm.__EVENTARGUMENT.value = eventArgument;
        theForm.submit();
    }
}
//]]>
</script>


<div>

    <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="/wEWDwKl98qhBAKD5baLBQKZnLKIBQLq34WTAgKNleXoCgKzupqdCgLp2rvfCALY7uLUDQLwl4zNDgLrm8LKAgLMx47jCALzy/PbBQK8/OrEAgKC5Ne7CQKM54rGBtJ+aAZBFYcd1GJp14FQ2yGOadeY" />
</div>

        <fieldset>

        <legend>Section A</legend>

        <dl>

            <dt><label for="occurrence_dateTextBox" >Occurrence Date:</label></dt>
            <dd><input name="occurrence_dateTextBox" type="text" id="occurrence_dateTextBox" size="50" /></dd>
        </dl>

        <dl>

            <dt><label for="report_dateTextBox">Report Date:</label></dt>
            <dd><input name="report_dateTextBox" type="text" id="report_dateTextBox" size="50" /></dd>
        </dl>


        <dl>

            <dt><label for="spec_idTextBox">Specimen ID:</label></dt>
            <dd><input name="spec_idTextBox" type="text" id="spec_idTextBox" size="50" /></dd>
        </dl>

        <dl>

            <dt><label for="batch_idTextBox">Batch ID:</label></dt>
            <dd><input name="batch_idTextBox" type="text" id="batch_idTextBox" size="50" /></dd>
        </dl>

        <dl>

            <dt><label for="report_byTextBox">Report By:</label></dt>
            <dd><input name="report_byTextBox" type="text" id="report_byTextBox" size="50" /></dd>
        </dl>

        <dl>

            <dt><label for="identified_byTextBox">Identified ID:</label></dt>
            <dd><input name="identified_byTextBox" type="text" id="identified_byTextBox" size="50" /></dd>
        </dl>

        </fieldset>

        <fieldset>
        <legend>Section B</legend>

        <dl>

            <dt><label for="problemTextBox">Problem:</label></dt>
            <dd><input name="problemTextBox" type="text" id="problemTextBox" size="50" /></dd>


        </dl>

        <dl>
            <dt><label for="lstProblems">Problems List:</label></dt>
            <dd><select size="4" name="lstProblems" multiple="multiple" id="lstProblems" style="height:100%;">

</select></dd>

        </dl>

        </fieldset>

        <fieldset>
        <legend>Section C</legend>
        <dl>

            <dt><label for="section_c_issue_error_identified_byTextBox">Issue/Error Identified By:</label></dt>
            <dd><input name="section_c_issue_error_identified_byTextBox" type="text" id="section_c_issue_error_identified_byTextBox" size="50" /></dd>


        </dl>

        <dl>

            <dt><label for="section_c_commentsTextBox">Comments:</label></dt>
            <dd><input name="section_c_commentsTextBox" type="text" id="section_c_commentsTextBox" size="50" /></dd>


        </dl>

        </fieldset>

        <fieldset>
        <legend>Section D</legend>
        <dl>

            <dt><label for="section_d_investigationTextBox">Investigation:</label></dt>
            <dd><input name="section_d_investigationTextBox" type="text" id="section_d_investigationTextBox" size="50" /></dd>


        </dl>

        </fieldset>

        <fieldset>
        <legend>Section E</legend>
        <dl>

            <dt><label for="section_e_corrective_actionTextBox">Corrective Action:</label></dt>
            <dd><textarea name="section_e_corrective_actionTextBox" rows="2" cols="20" id="section_e_corrective_actionTextBox" size="50" style="height:200px;"></textarea></dd>


        </dl>


        </fieldset>

        <fieldset>
        <legend>Section F</legend>
        <dl>

            <dt><label for="section_f_commentsTextBox">Comments:</label></dt>
            <dd><input name="section_f_commentsTextBox" type="text" id="section_f_commentsTextBox" size="50" /></dd>


        </dl>

        </fieldset>

        <fieldset>
        <legend>Pre-Analytical</legend>
        <dl>

            <dt><label for="prePracticeCodeTextBox">Practice Code:</label></dt>
            <dd></dd>


        </dl>

        <dl>

            <dt><label for="preContactTextBox1">Contact:</label></dt>
            <dd></dd>


        </dl>

        <dl>
            <dt><label for="CheckBox1">PreAnalytical?</label></dt>
            <dd> <span OnCheckChanged="CheckBox1_CheckedChanged"><input id="CheckBox1" type="checkbox" name="CheckBox1" onclick="javascript:setTimeout('__doPostBack(\'CheckBox1\',\'\')', 0)" /></span></dd>
        </dl>


        </fieldset>


        <input type="submit" name="Button1" value="Button" id="Button1" />


    </form>
</div></body>
</html>