Untitled

<html>
<head>
<title>Daily Site Report</title>
</head>
<body bgcolor="#FFFFFF" leftmargin=4 marginwidth=0 marginheight=4 topmargin=4>
	<form name="aggregateEntryForm" method="post" action="aggregate-reports-2">
		<input type=hidden name=site value=3>
		<input type=hidden name=report_type value=daily_report>
		<input type=hidden name=start_date value=2009-05-26>
		<input type=hidden name=end_date value=2009-05-26>
        	<table width=100%>
	        	<tr align=center>
				<th>Site: Cange</th>
				<th>Date: 2009/May/26</th>
			</tr>
		</table>
		<table width=100% border=2 rules=rows cellpadding=5>
			<!-- coded -->
			<tr bgcolor=#afdfbf><th colspan=2>Equipment Status</th><tr>
			<tr align=left><td width=50% align=right>Electricity Working</td>
				<td width=50% align=left>
					<input type=radio name=formData.electricity_working value=t>oui
					<input type=radio name=formData.electricity_working value=f>non
					<input type=text size=20 name=formData.electricity_working_txt value="">
					<input type=radio name=formData.electricity_working value=NA>Pas Disponible
				</td>
			</tr>
			<tr align=left><td width=50% align=right>Generator Working</td>
				<td width=50% align=left>
					<input type=radio name=formData.generator_working value=t>oui
					<input type=radio name=formData.generator_working value=f>non
					<input type=text size=20 name=formData.generator_working_txt value="">
					<input type=radio name=formData.generator_working value=NA>Pas Disponible
				</td>
			</tr>
			<!-- numeic -->
			<tr bgcolor=#afdfbf><th colspan=2>Number of Vaccinations Performed</th><tr>
			<tr align=left>
				<td width=50% align=right>Adults</td>
				<td width=50% align=left>
					<input type=text size=5 name=formData.vaccination_adult value="">
				</td>
			</tr>
			<tr align=left>
				<!-- numeric -->
				<td width=50% align=right>Children</td>
				<td width=50% align=left>
					<input type=text size=5 name=formData.vaccination_child value="">
				</td>
			</tr>
			<tr bgcolor=#afdfbf><th colspan=2>Mobile Clinics</th><tr>
			<tr align=left>
				<td width=50% align=right>Was there a mobile clinic today?</td>
				<!-- Coded -->
				<td width=50% align=left>
					<input type=radio name=formData.mobile_clinic value=t>Yes
					<input type=radio name=formData.mobile_clinic value=f>No
					<input type=radio name=formData.mobile_clinic value=NA>N/A
				</td>
			</tr>
			<tr align=left>
				<!-- numeric -->
				<td width=50% align=right># of Children Seen</td>
        			<td width=50% align=left>
					<input type=text size=5 name=formData.mobile_child value="">
				</td>
			</tr>
			<tr align=left>
				<!-- numeric -->
				<td width=50% align=right># of Adults Seen</td>
				<td width=50% align=left>
					<input type=text size=5 name=formData.mobile_adult value="">
				</td>
			</tr>
			<!-- stock question -->
			<tr bgcolor=#afdfbf><th colspan=2>Stock Status - Vaccinations</th><tr>
			<tr align=left>
				<td width=50% align=right>Measles</td>
				<td width=50% align=left>
					<select name=formData.vac_measles>
						<option value="" selected > </option>
						<option value=no_stock_out>In Stock</option>
						<option value=stock_out>Out of Stock</option>
						<option value=stock_expired>All Stock Expired</option>
						<option value=not_applicable_at_site>N/A</option>
					</select>
					for <input type=text size=5 name=formData.vac_measles_days value="" /> days
					<input type=text size=20 name=formData.vac_measles_txt value="">
				</td>
			</tr>
			<tr align=left>
				<td width=50% align=right>Polio</td>
				<td width=50% align=left>
        				<select name=formData.vac_polio>
						<option value="" selected > </option>
						<option value=no_stock_out>In Stock</option>
						<option value=stock_out>Out of Stock</option>
						<option value=stock_expired>All Stock Expired</option>
						<option value=not_applicable_at_site>N/A</option>
					</select>
					for <input type=text size=5 name=formData.vac_polio_days value="" /> days
					<input type=text size=20 name=formData.vac_polio_txt value="">
				</td>
			</tr>
			<tr align=left>
				<td width=50% align=right>Tetanus</td>
				<td width=50% align=left>
					<select name=formData.vac_tetanus>
						<option value="" selected > </option>
						<option value=no_stock_out>In Stock</option>
						<option value=stock_out>Out of Stock</option>
						<option value=stock_expired>All Stock Expired</option>
						<option value=not_applicable_at_site>N/A</option>
					</select>
					for <input type=text size=5 name=formData.vac_tetanus_days value="" /> days
					<input type=text size=20 name=formData.vac_tetanus_txt value="">
				</td>
			</tr>
		</table>
	</form>
</body>
</html>