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demographics.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta name="viewport" content="width=device-width, initial-scale=1.0" />
<title>NYEIS Dashboard</title>
<link
href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.3/dist/css/bootstrap.min.css"
rel="stylesheet"
integrity="sha384-QWTKZyjpPEjISv5WaRU9OFeRpok6YctnYmDr5pNlyT2bRjXh0JMhjY6hW+ALEwIH"
crossorigin="anonymous"
/>
<link rel="stylesheet" href="style.css" />
</head>
<body>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta
name="viewport"
content="width=device-width, initial-scale=1.0"
/>
<title>NYEIS Dashboard</title>
<link
href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.3/dist/css/bootstrap.min.css"
rel="stylesheet"
integrity="sha384-QWTKZyjpPEjISv5WaRU9OFeRpok6YctnYmDr5pNlyT2bRjXh0JMhjY6hW+ALEwIH"
crossorigin="anonymous"
/>
<link rel="stylesheet" href="style.css" />
</head>
<body>
<div class="container-fluid">
<form id="referralForm">
<div class="row">
<div class="col">
<header class="header" id="headerOrange">
Create Referral
</header>
</div>
<!-- End of first header row -->
</div>
<!-- Referral Source Section -->
<section>
<div class="row">
<div class="col">
<header class="header">
Referral Reason
</header>
</div>
<!-- End of Second Header Row -->
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Primary Referral Source:</p>
</div>
<div class="col-3">
Search Box Span for search box reset input
field
</div>
<div class="col-3 formHeader">
<p>Status Assigned:</p>
</div>
<div class="col-3">
<select id="demoStatusAssigned" required>
<option></option>
<option>At Risk</option>
<option>Suspected of Delay</option>
</select>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Secondary Referral Source:</p>
</div>
<div class="col-3">Search Bar</div>
</div>
<div class="row">
<div class="col-6 formHeader">
<p>Referral Source Type:</p>
</div>
<div class="col-6">
<select required>
<option></option>
<option>Something</option>
</select>
</div>
</div>
</section>
<!-- Child Info Section -->
<section>
<div class="row">
<div class="col">
<header class="header">
Child Information
</header>
</div>
<!-- End of Third Header Row -->
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Referral Date:</p>
</div>
<div class="col-3"></div>
<div class="col-3 formHeader">
<p>Child First Name:</p>
</div>
<div class="col-3">
<input
type="text"
id="demoChildFirstName"
/>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Child Middle Name:</p>
</div>
<div class="col-3">
<input
id="demoChildMiddleName"
type="text"
/>
</div>
<div class="col-3 formHeader">
<p>Child Last Name:</p>
</div>
<div class="col-3">
<input id="demoChildLastName" />
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Suffix:</p>
</div>
<div class="col-3">
<select id="demoChildSuffix">
<option></option>
<option>Jr</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Birth Last Name (If Different):</p>
</div>
<div class="col-3">
<input id="demoBirthLastName" type="text" />
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Gender:</p>
</div>
<div class="col-3">
<select>
<option>Select a gender</option>
<option>Male</option>
<option>Female</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Date of Birth:</p>
</div>
<div class="col-3">
<input id="demoDob" type="date" />
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Child's Dominant Language</p>
</div>
<div class="col-3">
<select id="childLanguage" required>
<option value="">
Select a language
</option>
<option value="amharic">Amharic</option>
<option value="arabic">Arabic</option>
<option value="armenian">
Armenian
</option>
<option value="bengali">Bengali</option>
<option value="bosnian">Bosnian</option>
<option value="burmese">Burmese</option>
<option value="cambodian">
Cambodian
</option>
<option value="chinese">Chinese</option>
<option value="dutch">Dutch</option>
<option value="english">English</option>
<option value="french">French</option>
<option value="german">German</option>
<option value="greek">Greek</option>
<option value="gujarati">
Gujarati
</option>
<option value="haitian">Haitian</option>
<option value="hebrew">Hebrew</option>
<option value="hindi">Hindi</option>
<option value="hmong">Hmong</option>
<option value="igbo">Igbo</option>
<option value="italian">Italian</option>
<option value="japanese">
Japanese
</option>
<option value="korean">Korean</option>
<option value="kurdish">Kurdish</option>
<option value="laotian">Laotian</option>
<option value="nepali">Nepali</option>
<option value="pashto">Pashto</option>
<option value="persian">Persian</option>
<option value="polish">Polish</option>
<option value="portuguese">
Portuguese
</option>
<option value="punjabi">Punjabi</option>
<option value="russian">Russian</option>
<option value="serbo-croatian">
Serbo-Croatian
</option>
<option value="somali">Somali</option>
<option value="spanish">Spanish</option>
<option value="swahili">Swahili</option>
<option value="tagalog">Tagalog</option>
<option value="telugu">Telugu</option>
<option value="thai">Thai</option>
<option value="tigrinya">
Tigrinya
</option>
<option value="turkish">Turkish</option>
<option value="urdu">Urdu</option>
<option value="vietnamese">
Vietnamese
</option>
<option value="yiddish">Yiddish</option>
<option value="yoruba">Yoruba</option>
<option value="other">Other</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Municipality of Residence:</p>
</div>
<div class="col-3">
<select
id="county"
class="form-select"
required
>
<option value="">
Select a county
</option>
<option value="albany">Albany</option>
<option value="allegany">
Allegany
</option>
<option value="bronx">Bronx</option>
<option value="broome">Broome</option>
<option value="cattaraugus">
Cattaraugus
</option>
<option value="cayuga">Cayuga</option>
<option value="chautauqua">
Chautauqua
</option>
<option value="chemung">Chemung</option>
<option value="chenango">
Chenango
</option>
<option value="clinton">Clinton</option>
<option value="columbia">
Columbia
</option>
<option value="cortland">
Cortland
</option>
<option value="delaware">
Delaware
</option>
<option value="dutchess">
Dutchess
</option>
<option value="erie">Erie</option>
<option value="essex">Essex</option>
<option value="franklin">
Franklin
</option>
<option value="fulton">Fulton</option>
<option value="genesee">Genesee</option>
<option value="greene">Greene</option>
<option value="hamilton">
Hamilton
</option>
<option value="herkimer">
Herkimer
</option>
<option value="jefferson">
Jefferson
</option>
<option value="kings">Kings</option>
<option value="lewis">Lewis</option>
<option value="livingston">
Livingston
</option>
<option value="madison">Madison</option>
<option value="monroe">Monroe</option>
<option value="montgomery">
Montgomery
</option>
<option value="nassau">Nassau</option>
<option value="new_york">
New York
</option>
<option value="niagara">Niagara</option>
<option value="oneida">Oneida</option>
<option value="onondaga">
Onondaga
</option>
<option value="ontario">Ontario</option>
<option value="orange">Orange</option>
<option value="orleans">Orleans</option>
<option value="oswego">Oswego</option>
<option value="otsego">Otsego</option>
<option value="putnam">Putnam</option>
<option value="queens">Queens</option>
<option value="rensselaer">
Rensselaer
</option>
<option value="richmond">
Richmond
</option>
<option value="rockland">
Rockland
</option>
<option value="saint_lawrence">
Saint Lawrence
</option>
<option value="saratoga">
Saratoga
</option>
<option value="schenectady">
Schenectady
</option>
<option value="schoharie">
Schoharie
</option>
<option value="schuyler">
Schuyler
</option>
<option value="seneca">Seneca</option>
<option value="steuben">Steuben</option>
<option value="suffolk">Suffolk</option>
<option value="sullivan">
Sullivan
</option>
<option value="tioga">Tioga</option>
<option value="tompkins">
Tompkins
</option>
<option value="ulster">Ulster</option>
<option value="warren">Warren</option>
<option value="washington">
Washington
</option>
<option value="wayne">Wayne</option>
<option value="westchester">
Westchester
</option>
<option value="wyoming">Wyoming</option>
<option value="yates">Yates</option>
</select>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Race:</p>
</div>
<div class="col-3">
<select>
<option>Select a race</option>
<option>
American Indian or Alaskan Native
</option>
<option>Asian</option>
<option>
Black or African American
</option>
<option>
Native Hawaiian or Other Pacific
Islander
</option>
<option>White</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Ethnicity:</p>
</div>
<div class="col-3">
<select
id="ethnicity"
class="form-select"
required
>
<option value="">
Select an ethnicity
</option>
<option value="hispanic_or_latino">
Hispanic or Latino
</option>
<option value="not_hispanic_or_latino">
Not Hispanic or Latino
</option>
</select>
</div>
</div>
</section>
<!-- Family Info Section -->
<section>
<div class="row">
<div class="col">
<header class="header">
Family Information
</header>
</div>
<!-- End of Fourth Header Row -->
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Mother's First Name:</p>
</div>
<div class="col-3">
<input
id="demoMotherFirstName"
type="text"
/>
</div>
<div class="col-3 formHeader">
<p>Mother's Last Name:</p>
</div>
<div class="col-3">
<input
id="demoMotherLastName"
type="text"
/>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Mother's Date of Birth:</p>
</div>
<div class="col-3">
<input id="demoMotherDOB" type="date" />
</div>
<div class="col-3 formHeader">
<p>Mother's Dominant Language:</p>
</div>
<div class="col-3">
<select id="motherLanguage" required>
<option value="">
Select a language
</option>
<option value="amharic">Amharic</option>
<option value="arabic">Arabic</option>
<option value="armenian">
Armenian
</option>
<option value="bengali">Bengali</option>
<option value="bosnian">Bosnian</option>
<option value="burmese">Burmese</option>
<option value="cambodian">
Cambodian
</option>
<option value="chinese">Chinese</option>
<option value="dutch">Dutch</option>
<option value="english">English</option>
<option value="french">French</option>
<option value="german">German</option>
<option value="greek">Greek</option>
<option value="gujarati">
Gujarati
</option>
<option value="haitian">Haitian</option>
<option value="hebrew">Hebrew</option>
<option value="hindi">Hindi</option>
<option value="hmong">Hmong</option>
<option value="igbo">Igbo</option>
<option value="italian">Italian</option>
<option value="japanese">
Japanese
</option>
<option value="korean">Korean</option>
<option value="kurdish">Kurdish</option>
<option value="laotian">Laotian</option>
<option value="nepali">Nepali</option>
<option value="pashto">Pashto</option>
<option value="persian">Persian</option>
<option value="polish">Polish</option>
<option value="portuguese">
Portuguese
</option>
<option value="punjabi">Punjabi</option>
<option value="russian">Russian</option>
<option value="serbo-croatian">
Serbo-Croatian
</option>
<option value="somali">Somali</option>
<option value="spanish">Spanish</option>
<option value="swahili">Swahili</option>
<option value="tagalog">Tagalog</option>
<option value="telugu">Telugu</option>
<option value="thai">Thai</option>
<option value="tigrinya">
Tigrinya
</option>
<option value="turkish">Turkish</option>
<option value="urdu">Urdu</option>
<option value="vietnamese">
Vietnamese
</option>
<option value="yiddish">Yiddish</option>
<option value="yoruba">Yoruba</option>
<option value="other">Other</option>
</select>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Fathers's First Name:</p>
</div>
<div class="col-3">
<input
id="demoFatherFirstName"
type="text"
/>
</div>
<div class="col-3 formHeader">
<p>Father's Last Name:</p>
</div>
<div class="col-3">
<input
id="demoFatherLastName"
type="text"
/>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Father's Date of Birth:</p>
</div>
<div class="col-3">
<input id="demoFatherDOB" type="date" />
</div>
<div class="col-3 formHeader">
<p>Father's Dominant Language:</p>
</div>
<div class="col-3">
<select id="demofatherLanguage" required>
<option value="">
Select a language
</option>
<option value="amharic">Amharic</option>
<option value="arabic">Arabic</option>
<option value="armenian">
Armenian
</option>
<option value="bengali">Bengali</option>
<option value="bosnian">Bosnian</option>
<option value="burmese">Burmese</option>
<option value="cambodian">
Cambodian
</option>
<option value="chinese">Chinese</option>
<option value="dutch">Dutch</option>
<option value="english">English</option>
<option value="french">French</option>
<option value="german">German</option>
<option value="greek">Greek</option>
<option value="gujarati">
Gujarati
</option>
<option value="haitian">Haitian</option>
<option value="hebrew">Hebrew</option>
<option value="hindi">Hindi</option>
<option value="hmong">Hmong</option>
<option value="igbo">Igbo</option>
<option value="italian">Italian</option>
<option value="japanese">
Japanese
</option>
<option value="korean">Korean</option>
<option value="kurdish">Kurdish</option>
<option value="laotian">Laotian</option>
<option value="nepali">Nepali</option>
<option value="pashto">Pashto</option>
<option value="persian">Persian</option>
<option value="polish">Polish</option>
<option value="portuguese">
Portuguese
</option>
<option value="punjabi">Punjabi</option>
<option value="russian">Russian</option>
<option value="serbo-croatian">
Serbo-Croatian
</option>
<option value="somali">Somali</option>
<option value="spanish">Spanish</option>
<option value="swahili">Swahili</option>
<option value="tagalog">Tagalog</option>
<option value="telugu">Telugu</option>
<option value="thai">Thai</option>
<option value="tigrinya">
Tigrinya
</option>
<option value="turkish">Turkish</option>
<option value="urdu">Urdu</option>
<option value="vietnamese">
Vietnamese
</option>
<option value="yiddish">Yiddish</option>
<option value="yoruba">Yoruba</option>
<option value="other">Other</option>
</select>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Is a Parent Proficient in English:</p>
</div>
<div class="col-3">
<select id="demoProficientInEnglish">
<option>Yes</option>
<option>No</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Preferred Communication:</p>
</div>
<div class="col-3">
<select id="demoPreferredCommunication">
<option></option>
<option>Phone</option>
<option>Email</option>
<option>Letter</option>
</select>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Alternate Parent Contact Name:</p>
</div>
<div class="col-3">
<input id="demoAltParentName" type="text" />
</div>
<div class="col-3 formHeader">
<p>
Phone Number of Alternate Parent Contact
Person:
</p>
</div>
<div class="col-3">
<input
id="demoAltPhoneNumber"
type="number"
/>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>
Alternate Contact's Relationship to
Child
</p>
</div>
<div class="col-3">
<input
id="demoAltParentRelationship"
type="text"
/>
</div>
<div class="col-6"></div>
</div>
<div class="row">
<div class="col-3">
<input
id="demoParentAwareCheck"
type="checkbox"
/>
</div>
<div class="col-9 formHeader">
<p id="demoParentAwareNotice">
By submitting this referral, I attest
that the parent/legal guardian was
consulted and she/he did not object to
the referral.
</p>
</div>
</div>
</section>
<!-- Address Section -->
<section>
<div class="row">
<div class="col">
<header class="header">Address</header>
</div>
<!-- End of Fourth Header Row -->
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Primary Address:</p>
</div>
<div class="col-3">
<button>Search Address</button>
</div>
<div class="col-3 formHeader">
<p>Mailing Address</p>
</div>
<div class="col-3">
<button>Search Mailing Address</button>
</div>
</div>
</section>
<!-- Phone # Section -->
<section>
<div class="row">
<div class="col">
<header class="header">Phone Number</header>
</div>
<!-- End of Fourth Header Row -->
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Type:</p>
</div>
<div class="col-3">
<select id="demoPhoneType">
<option></option>
<option>Main</option>
<option>Mobile</option>
<option>Home</option>
<option>Work</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Phone Number:</p>
</div>
<div class="col-3">
<input id="demoPhoneNumber" type="number" />
</div>
</div>
</section>
<!-- Parental Conscent Section -->
<section>
<div class="row">
<div class="col">
<header class="header">
Parental Consent
</header>
</div>
<!-- End of Fourth Header Row -->
</div>
<div class="row">
<div class="col">
<p id="demoConsentNotice">
Capturing the information below requires
that informed parental consent has been
obtained. Your information will not be
saved or submitted if you have not
indicated that parental consent has been
captured.
</p>
</div>
</div>
<div class="row">
<div class="col-3">
<input
id="demoParentInformedConsent"
type="checkbox"
/>
</div>
<div class="col-9 formHeader">
<p id="demoParentAwareNotice">
Informed Parental Consent Obtained?
</p>
</div>
</div>
</section>
<!-- Child Details Section -->
<section>
<div class="row">
<div class="col">
<header class="header">
Child Details
</header>
</div>
<!-- End of Fourth Header Row -->
</div>
<div class="row">
<div class="col-3 formHeader">
<p>
Caregiver Name (If Other Than Parent):
</p>
</div>
<div class="col-3">
<input
type="text"
id="demoAltCaregiverName"
/>
</div>
<div class="col-3 formHeader">
<p>Caregiver's Relationship:</p>
</div>
<div class="col-3">
<select id="demoCaregiverRelationship">
<option></option>
<option>Test</option>
</select>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Child's Living Arrangement:</p>
</div>
<div class="col-3">
<select id="demoChildsLivingArrangement">
<option></option>
<option>Test</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Child's School District:</p>
</div>
<div class="col-3">
<select id="demoCaregiverRelationship">
<option></option>
<option>Test</option>
</select>
</div>
</div>
</section>
<!-- Comm Exception Section-->
<section>
<div class="row">
<div class="col">
<header class="header">
Communication Exception
</header>
</div>
<!-- End of Fourth Header Row -->
</div>
<div class="row">
<div class="col-3 formHeader">
<p>Method:</p>
</div>
<div class="col-3">
<select id="demoMethod">
<option></option>
<option>Test</option>
</select>
</div>
<div class="col-3 formHeader">
<p>Reason:</p>
</div>
<div class="col-3">
<select id="demoReason">
<option></option>
<option>Test</option>
</select>
</div>
</div>
<div class="row">
<div class="col-3 formHeader">
<p>From:</p>
</div>
<div class="col-3">Search function</div>
<div class="col-3 formHeader">
<p>To:</p>
</div>
<div class="col-3">Search function</div>
</div>
</section>
<!-- Suspected of Delay Referral Details Section -->
<section>
<div class="row">
<div class="col">
<header class="header">
Suspected of Delay Referral Details
</header>
</div>
<!-- End of Fourth Header Row -->
</div>
<!-- Row 1 -->
<div class="row">
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoPrimaryReferralReason"
/>
</div>
<div class="col-5 formHeader">
<p>Primary Referral Reason</p>
</div>
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoSecondaryReferralReason"
/>
</div>
<div class="col-5 formHeader">
<p>Secondary Referral Reason</p>
</div>
</div>
<!-- Row 2 -->
<div class="row">
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoPrimaryConfirmed"
/>
</div>
<div class="col-5 formHeader">
<p>Confirmed Diagnosed Condition</p>
</div>
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoSecondaryConfirmed"
/>
</div>
<div class="col-5 formHeader">
<p>Confirmed Diagnosed Condition</p>
</div>
</div>
<!-- Row 3 -->
<div class="row">
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoPrimaryAdaptive"
/>
</div>
<div class="col-5 formHeader">
<p>Adaptive</p>
</div>
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoSecondaryAdaptive"
/>
</div>
<div class="col-5 formHeader">
<p>Adaptive</p>
</div>
</div>
<!-- Row 4 -->
<div class="row">
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoPrimaryCognitive"
/>
</div>
<div class="col-5 formHeader">
<p>Cognitive</p>
</div>
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoSecondaryCognitive"
/>
</div>
<div class="col-5 formHeader">
<p>Cognitive</p>
</div>
</div>
<!-- Row 5 -->
<div class="row">
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoPrimaryCommunication"
/>
</div>
<div class="col-5 formHeader">
<p>Communication</p>
</div>
<div class="col-1 formHeader">
<input
type="checkbox"
id="demoSecondaryCommunication"
/>
</div>
<div class="col-5 formHeader">
<p>Communication</p>
</div>
</div>
<!-- Row 6 -->
<div class="row">
<div class="col-1 formHeader">
<input
type="checkbox"