@extends( 'layouts.master' )

@section( 'script' )

@parent

<script type="text/javascript" src="//code.jquery.com/jquery-1.12.0.min.js"></script>
<script type="text/javascript" src="//code.jquery.com/ui/1.12.0/jquery-ui.min.js"></script>
<script type="text/javascript" src="{!! asset('js/jquery.timepicker.min.js') !!}"></script>
<script type="text/javascript" src="http://ajax.googleapis.com/ajax/libs/dojo/1.4/dojo/dojo.xd.js"></script>
<script type="text/javascript" src="{!! asset('js/submissionCommon.js') !!}"></script>

<script type="text/javascript">

$( document ).ajaxStart( function () {
	$("body").addClass("loading");
} ).ajaxStop( function () {
	$("body").removeClass("loading");
} );

$( function() {
	// Date picker for "Date Vaccine Administered:"
	$( ".date" ).datepicker( {
		changeMonth: true,
		changeYear: true,
		yearRange:  "-85:+0",					   
	} );

	// Country selection change states option
	$( ".country" ).change( function() {
		$selectState = $selectStates = $(this).parent().parent().find( ".state" );
		if ( $(this).val() != '' ) {
			$.ajax( {
				dataType: "json",
				url: "/getStates/" + $(this).val(),
				success: function( data ) {
					if ( data != null ) {
						$selectState.prop( 'disabled', '' );
						$selectState.empty();
						$selectState.append( $( '<option></optoin>' ).html( 'Choose a State' ) );
						$.each( data, function( index ) {
							$selectState.append( $( '<option></option>' ).val( index ).html( data[index] ) );
						} );
					} else {
						$selectState.prop( 'disabled', 'disabled' );
					}
				},
			} );
		}
	} );

	var dialog = $( "#vaccine-dialog" );
	$( ".vaccine-lookup" ).click( function() {
		var vaccineTable = $( this ).parent().find( ".vaccine-table" );
		$.ajax( {
		    url: "/getVaccineLookUp" ,
		    success: function( data ){
				dialog.dialog( {
					autoOpen: false,
					modal: true,
					title: "Vaccine Lookup:",
					height: 600,
					width: 450,
					buttons: {
						"Add Vaccine": function() {
							var adminIndex = vaccineTable.parent().find( ".admin-index" ).val();
							var vaccineIndex = vaccineTable.find( 'tr' ).length - 1;
							var label = $( "#vaccine-label" ).val();
							var iri = $( "#vaccine-iri" ).val();
							
							vaccineTable.find( 'tr:last' ).after(
'<tr class="vaccine-row">\
	<td>\
		<label class="vaccine-label-display">' + label + '</label>\
		<input name="admin[' + adminIndex + '][vaccine][label][]" type="hidden" class="vaccine-label" value="' + label + '" />\
		<input name="admin[' + adminIndex + '][vaccine][iri][]" type="hidden" class="vaccine-iri" value="' + iri + '" />\
	</td>\
	<td>\
		<div class="report_item">\
			<label></label>\
			<select name="admin[' + adminIndex + '][vaccine][manufacturer][]">\
				<option value></option>\
			</select>\
		</div>\
	</td>\
	<td>\
		<div class="report_item">\
			<label></label>\
			<input type="text" name="admin[' + adminIndex + '][vaccine][lot_number][]" />\
		</div>\
	</td>\
	<td>\
		<div class="report_item">\
			<label></label>\
			<select name="admin[' + adminIndex + '][vaccine][route][]">\
				<option value></option>\
				<option value="ID" >Intradermal - ID</option>\
				<option value="IJ" >Shot/Injection - IJ</option>\
				<option value="IM" >Intramuscular - IM</option>\
				<option value="IN" >Intranasal - IN</option>\
				<option value="PO" >Per Oral - PO</option>\
				<option value="SC" >Subcutaneous - SC/SQ</option>\
			</select>\
		</div>\
	</td>\
	<td>\
		<div class="report_item">\
			<label></label>\
			<select name="admin[' + adminIndex + '][vaccine][site][]">\
				<option value></option>\
				<option value="arm">arm</option>\
				<option value="right_arm">right arm</option>\
				<option value="left_arm">left arm</option>\
				<option value="leg">leg</option>\
				<option value="right_leg">right leg</option>\
				<option value="left_leg">left lag</option>\
				<option value="nose">nose</option>\
				<option value="buttocks">buttocks</option>\
			</select>\
		</div>\
	</td>\
	<td>\
		<div class="report_item">\
			<label></label>\
			<select name="admin[' + adminIndex + '][vaccine][previous_dose][]">\
				<option value></option>\
				<option value="1">1</option>\
				<option value="2">2</option>\
				<option value="3">3</option>\
				<option value="4">4</option>\
				<option value="5">5</option>\
			</select>\
		</div>\
	</td>\
	<td>\
		<button class="vaccine-remove" type="button">Remove</button>\
	</td>\
</tr>'
							);
							$( '.vaccine-remove' ).on( 'click', function() {
								console.log();
								$( this ).parent().parent().remove();
							} );
							dialog.dialog( "close" );
						},
						"Cancel": function() {
			                dialog.dialog( "close" );
						}
					}
				} ).dialog( "open" );
		    	dialog.html( data );
		    }   
		});
	} );

	$( '.vaccine-remove' ).on( 'click', function() {
		console.log();
		$( this ).parent().parent().remove();
	} );
} );

/* When the user clicks on the button, 
toggle between hiding and showing the dropdown content */
function showAdmin() {
    document.getElementById( "myDropdown" ).classList.toggle( "show" );
}

// Close the dropdown menu if the user clicks outside of it
window.onclick = function( event ) {
	if ( !event.target.matches( '.dropbtn' ) ) {
		var dropdowns = document.getElementsByClassName("dropdown-content");
		var i;
		for (i = 0; i < dropdowns.length; i++) {
			var openDropdown = dropdowns[i];
			if (openDropdown.classList.contains('show')) {
				openDropdown.classList.remove('show');
			}
		}
	}
}

</script>

@endsection

@section( 'style' )

@parent

<link rel="stylesheet" href="//code.jquery.com/ui/1.12.0/themes/smoothness/jquery-ui.css">
<link rel="stylesheet" type="text/css" href="http://ajax.googleapis.com/ajax/libs
<link rel="stylesheet" type="text/css" href="/css/jquery.timepicker.css" />

<style>
/* Dropdown Button */
.dropbtn {
    background-color: lightgrey;
    color: black;
    padding: 5px;
    font-size: 16px;
    font-weight: bold;
    border: none;
    cursor: pointer;
}

/* Dropdown button on focus */
.dropbtn:focus {
    background-color: #666666;
}

/* The container <div> - needed to position the dropdown content */
.dropdown {
    position: relative;
    display: inline-block;
}

/* Dropdown Content (Hidden by Default) */
.dropdown-content {
    display: none;
    position: absolute;
    background-color: #f9f9f9;
    min-width: 160px;
    box-shadow: 0px 8px 16px 0px rgba(0,0,0,0.2);
}

/* Links inside the dropdown */
.dropdown-content a {
    color: black;
    padding: 12px 16px;
    text-decoration: none;
    display: block;
}

/* Change color of dropdown links on hover */
.dropdown-content a:hover {background-color: #f1f1f1}

/* Show the dropdown menu (use JS to add this class to the .dropdown-content container when the user clicks on the dropdown button) */
.show {display:block;}

/* Start by setting display:none to make this hidden.
   Then we position it in relation to the viewport window
   with position:fixed. Width, height, top and left speak
   for themselves. Background we set to 80% white with
   our animation centered, and no-repeating */
.modal {
    display:    none;
    position:   fixed;
    z-index:    1000;
    top:        0;
    left:       0;
    height:     100%;
    width:      100%;
    background: rgba( 255, 255, 255, .8 ) 
                url( {!! asset('images/ajax-loader.gif') !!} )
                50% 50% 
                no-repeat;
}

/* When the body has the loading class, we turn
   the scrollbar off with overflow:hidden */
body.loading {
    overflow: hidden;   
}

/* Anytime the body has the loading class, our
   modal element will be visible */
body.loading .modal {
    display: block;
}

</style>

@endsection

@section( 'content' )

<table width="850" align="center">

<tr>
	<td>
		<h2>Report Adverse Event Online</h2>
		<h3>Step 2 of 3: Vaccine Administrative Information</h3>
		<label><span class="reqIndicator">*</span> = required field&nbsp;</label>
		
				
		<div align="right">
			<div class="dropdown">
				<button id="myDropdownBtn" onclick="showAdmin()" class="dropbtn">Select Vaccine Administration</button>
				<div id="myDropdown" class="dropdown-content">
					@foreach( $case->admin as $index => $value )
						<a href="{{ url( "/report/admin/$index" ) }}"><strong>Vaccine Administration #{{ $index + 1 }}</strong></a>
					@endforeach
					<a href="{{ url( "/report/admin/new" ) }}"><strong>Create new Vaccine Administration</strong></a>
				</div>
			</div>
		</div>
		
		<fieldset id="fieldset-{{ $adminIndex }}" name ="fieldset-{{ $adminIndex }}" value="0">
			
			<legend><h3>Vaccine Administration #{{ $adminIndex + 1 }}</h3></legend>
			
			<form id="form_admin" role="form" method="POST" action="{{ url( '/report' ) }}">
				{!! csrf_field() !!}
					
				<fieldset>
					<legend><span class="reqIndicator">*&nbsp;</span>Vaccines (required at least one)</legend>
				
					<div class="report_item">
					
						<input class="admin-index" type="hidden" value="{{ $adminIndex }}" />
						
						<input class="vaccine-lookup" type="button" value="Vaccine Look Up" />
						
						<table class="vaccine-table" border="0" cellpadding="4" cellspacing="1" bgcolor="#666666">
							<tr>
								<td bgcolor="#FFFFFF" width="25%"><label>Vaccine:</label></td>
								<td bgcolor="#FFFFFF" width="20%"><label>Manufacturer (Brand):</td>
								<td bgcolor="#FFFFFF" width="10%"><label>Lot Number:</label></td>
								<td bgcolor="#FFFFFF" width="10"><label>Route:</label></td>
								<td bgcolor="#FFFFFF" width="10%"><label>Site:</label></td>
								<td bgcolor="#FFFFFF" width="10%"><label>No. of Previous Doses:</label></td>
								<td bgcolor="#FFFFFF" width="5%"></td>
							</tr>
							@if( !empty( old( "admin.$adminIndex.vaccine" ) ) )
								@foreach( old( "admin.$adminIndex.vaccine" ) as $vaccineIndex => $vaccine )
									<tr class="vaccine-row">
										<td>
											<label class="vaccine-label-display">{{ $vaccine['label'] }}</label>												
											<input name="{{ "admin[$adminIndex][vaccine][label][]" }}" type="hidden" class="vaccine-label" value="{{ $vaccine['label'] }}" />
											<input name="{{ "admin[$adminIndex][vaccine][iri][]" }}" type="hidden" class="vaccine-iri" value="{{ $vaccine['iri'] }}" />
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][manufacturer][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.manufacturer",
												'sessionValue' => null,
												'defaultLabel' => '',
												'options' => [],
											] )
										</td>
										<td>
											@include( 'includes.form.text', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][lot_number][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.lot_number",
												'sessionValue' => null,
											] )
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][route][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.route",
												'sessionValue' => null,
												'defaultLabel' => '',
												'options' => ['ID'=>'Intradermal - ID', 'IJ'=>'Shot/Injection - IJ', 'IM'=>'Intramuscular - IM', 'IN'=>'Intranasal - IN', 'PO'=>'Per Oral - PO', 'SC'=>'Subcutaneous - SC/SQ'],
											] )
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][site][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.site",
												'sessionValue' => null,
												'defaultLabel' => '',
												'options' => ['arm'=>'arm', 'right_arm'=>'right arm', 'left_arm'=>'left arm', 'leg'=>'leg', 'right_leg'=>'right leg', 'left_leg'=>'left leg', 'nose'=>'nose', 'buttocks'=>'buttocks'],
											] )
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][previous_dose][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.previous_dose",
												'sessionValue' => null,
												'defaultLabel' => '',
												'options' => ['1'=>'1', '2'=>'2', '3'=>'3', '4'=>'4', '5'=>'5'],
											] )
										</td>
										<td>
											@if ( $errors->has( "admin.$adminIndex.vaccine.$vaccineIndex.label" ) )
												<span class="form-error-msg"><strong>{{ $errors->first( "admin.$adminIndex.vaccine.$vaccineIndex.label" ) }}</strong></span>
											@endif
											
											@if ( $errors->has( "admin.$adminIndex.vaccine.$vaccineIndex.iri" ) )
												<span class="form-error-msg"><strong>{{ $errors->first( "admin.$adminIndex.vaccine.$vaccineIndex.iri" ) }}</strong></span>
											@endif
											<button class="vaccine-remove" type="button">Remove</button>
										</td>
									</tr>
								@endforeach
							@elseif( !is_null( $admin->vaccine[0]->iri ) )
								@foreach( $admin->vaccine as $vaccineIndex => $vaccine )
									<tr class="vaccine-row">
										<td>
											<label class="vaccine-label-display">{{ !is_null( $vaccine->label ) ? $vaccine->label : old( "admin.$adminIndex.vaccine.$vaccineIndex.label" ) }}</label>												
											<input name="{{ "admin[$adminIndex][vaccine][label][]" }}" type="hidden" class="vaccine-label" value="{{ !is_null( $vaccine->label ) ? $vaccine->label : old( "admin.$adminIndex.vaccine.$vaccineIndex.label" ) }}" />
											<input name="{{ "admin[$adminIndex][vaccine][iri][]" }}" type="hidden" class="vaccine-iri" value="{{ !is_null( $vaccine->iri ) ? $vaccine->iri : old( "admin.$adminIndex.vaccine.$vaccineIndex.iri" ) }}" />
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][manufacturer][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.manufacturer",
												'sessionValue' => $vaccine->manufacturer,
												'defaultLabel' => '',
												'options' => [],
											] )
										</td>
										<td>
											@include( 'includes.form.text', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][lot_number][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.lot_number",
												'sessionValue' => $vaccine->lot_number,
											] )
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][route][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.route",
												'sessionValue' => $vaccine->route,
												'defaultLabel' => '',
												'options' => ['ID'=>'Intradermal - ID', 'IJ'=>'Shot/Injection - IJ', 'IM'=>'Intramuscular - IM', 'IN'=>'Intranasal - IN', 'PO'=>'Per Oral - PO', 'SC'=>'Subcutaneous - SC/SQ'],
											] )
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][site][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.site",
												'sessionValue' => $vaccine->site,
												'defaultLabel' => '',
												'options' => ['arm'=>'arm', 'right_arm'=>'right arm', 'left_arm'=>'left arm', 'leg'=>'leg', 'right_leg'=>'right leg', 'left_leg'=>'left leg', 'nose'=>'nose', 'buttocks'=>'buttocks'],
											] )
										</td>
										<td>
											@include( 'includes.form.select', [
												'label' => '',
												'name' => "admin[$adminIndex][vaccine][previous_dose][]",
												'oldName' => "admin.$adminIndex.vaccine.$vaccineIndex.previous_dose",
												'sessionValue' => $vaccine->previous_dose,
												'defaultLabel' => '',
												'options' => ['1'=>'1', '2'=>'2', '3'=>'3', '4'=>'4', '5'=>'5'],
											] )
										</td>
										<td>
											@if ( $errors->has( "admin.$adminIndex.vaccine.$vaccineIndex.label" ) )
												<span class="form-error-msg"><strong>{{ $errors->first( "admin.$adminIndex.vaccine.$vaccineIndex.label" ) }}</strong></span>
											@endif
											
											@if ( $errors->has( "admin.$adminIndex.vaccine.$vaccineIndex.iri" ) )
												<span class="form-error-msg"><strong>{{ $errors->first( "admin.$adminIndex.vaccine.$vaccineIndex.iri" ) }}</strong></span>
											@endif
											<button class="vaccine-remove" type="button">Remove</button>
										</td>
									</tr>
								@endforeach
							@endif
						</table>
					</div>
				</fieldset>
					
				<br />
				
				<div class="report_item">
					<label><span class="reqIndicator">*</span> Date Vaccine Administered (mm/dd/yyyy):</label>
					<input class="date" name="admin[{{ $adminIndex }}][date]" type="text" size="10" maxlength="10" value="{{ !is_null( $admin->date ) ? $admin->date : old( "admin.$adminIndex.date" ) }}" title="Date Vaccine Administered"/>
				</div>
				@if ( $errors->has( "admin.$adminIndex.date" ) )
					<span class="form-error-msg"><strong>{{ $errors->first( "admin.$adminIndex.date" ) }}</strong></span>
				@endif
				
				@include( 'includes.form.text', [
					'label' => 'Time Vaccine Administered (eg. AM, 6:15 PM):',
					'name' => "admin[$adminIndex][time]",
					'oldName' => "admin.$adminIndex.time",
					'sessionValue' => $admin->time,
				] )
				
				<br />
				
				@include( 'includes.form.select', [
					'label' => 'Vaccinated At:',
					'name' => "admin[$adminIndex][location]",
					'oldName' => "admin.$adminIndex.location",
					'sessionValue' => $admin->location,
					'defaultLabel' => 'Choose One',
					'options' => [
						'private_doctor' => 'Private doctor\'s office/hospital',
						'public_doctor' => 'Public health clinic/hospital',
						'military_doctor' => 'Military clinic/hospital',
						'other' => 'Other/unknown',
					],
				] )
				
				<br />
				
				@include( 'includes.form.select', [
					'label' => 'Vaccine Purchased With:',
					'name' => "admin[$adminIndex][purchase]",
					'oldName' => "admin.$adminIndex.purchase",
					'sessionValue' => $admin->purchase,
					'defaultLabel' => 'Choose One',
					'options' => [
						'private_funds' => 'Private funds',
						'public_funds' => 'Public funds',
						'military_funds' => 'Military funds',
						'other' => 'Other/unknown',
					],
				] )
				
				<br />
				
				@include( 'includes.form.textbox', [
					'label' => 'Any Illnesses at Time of Vaccination?:',
					'rows' => '4',
					'cols' => '80',
					'name' => "admin[$adminIndex][illness]",
					'oldName' => "admin.$adminIndex.illness",
					'sessionValue' => $admin->illness,
				] )
				
				<br />
				
				@include( 'includes.form.textbox', [
					'label' => 'Pre-existing Physician-Diagnosed Allergies, Birth Defects, Medical Conditions at Time of Vaccination:',
					'rows' => '4',
					'cols' => '80',
					'name' => "admin[$adminIndex][previous_illness]",
					'oldName' => "admin.$adminIndex.previous_illness",
					'sessionValue' => $admin->previous_illness,
				] )
				
				<br />
				
				<fieldset>
					<legend>Vaccine Administrator</legend>
					
					@include( 'includes.form.text', [
						'label' => 'First Name:',
						'name' => "admin[$adminIndex][admin_first_name]",
						'oldName' => "admin.$adminIndex.admin_first_name",
						'sessionValue' => $admin->admin_first_name,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'Last Name:',
						'name' => "admin[$adminIndex][admin_last_name]",
						'oldName' => "admin.$adminIndex.admin_last_name",
						'sessionValue' => $admin->admin_last_name,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'MI:',
						'name' => "admin[$adminIndex][admin_middle_name]",
						'oldName' => "admin.$adminIndex.admin_middle_name",
						'sessionValue' => $admin->admin_middle_name,
					] )
				</fieldset>
				
				<br />
				
				<fieldset>
					<legend>Responsible Physician</legend>
					
					@include( 'includes.form.text', [
						'label' => 'First Name:',
						'name' => "admin[$adminIndex][physician_first_name]",
						'oldName' => "admin.$adminIndex.physician_first_name",
						'sessionValue' => $admin->physician_first_name,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'Last Name:',
						'name' => "admin[$adminIndex][physician_last_name]",
						'oldName' => "admin.$adminIndex.physician_last_name",
						'sessionValue' => $admin->physician_last_name,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'MI:',
						'name' => "admin[$adminIndex][physician_middle_name]",
						'oldName' => "admin.$adminIndex.physician_middle_name",
						'sessionValue' => $admin->physician_middle_name,
					] )
				</fieldset>
				
				<br />
				
				<fieldset >
					<legend>Facility</legend>
					
					@include( 'includes.form.text', [
						'label' => 'Facility Name:',
						'name' => "admin[$adminIndex][facility_name]",
						'size' => '50',
						'oldName' => "admin.$adminIndex.facility_name",
						'sessionValue' => $admin->facility_name,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'Address:',
						'name' => "admin[$adminIndex][facility_address_1]",
						'size' => '100',
						'oldName' => "admin.$adminIndex.facility_address_1",
						'sessionValue' => $admin->facility_address_1,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'Address 2:',
						'name' => "admin[$adminIndex][facility_address_2]",
						'size' => '100',
						'oldName' => "admin.$adminIndex.facility_address_2",
						'sessionValue' => $admin->facility_address_2,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'City:',
						'name' => "admin[$adminIndex][facility_city]",
						'size' => '75',
						'oldName' => "admin.$adminIndex.facility_city",
						'sessionValue' => $admin->facility_city,
					] )
					
					@include( 'includes.form.select', [
						'label' => 'County Where Vaccine Was Administered:',
						'class' => 'country',
						'name' => "admin[$adminIndex][facility_country]",
						'oldName' => "admin.$adminIndex.facility_country",
						'sessionValue' => $admin->facility_country,
						'defaultLabel' => 'Choose a Country',
						'options' => ['US' => 'United State', 'CN' => 'China', 'TW' => 'Taiwan'],
					] )
					
					{{ $oldCountry = old( "admin.$adminIndex.facility_country" ) }}
										@include( 'includes.form.select' , [
						'label' => 'State Where Vaccine Was Administered:',
						'class' => 'state',
						'name' => "admin[$adminIndex][facility_state]",
						'oldName' => "admin.$adminIndex.facility_state",
						'sessionValue' => $admin->facility_state,
						'defaultLabel' => 'Choose a State',
						'options' => $stateOptions,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'Postal Code:',
						'name' => "admin[$adminIndex][facility_zip]",
						'size' => '10',
						'oldName' => "admin.$adminIndex.facility_zip",
						'sessionValue' => $admin->facility_zip,
					] )
					
					@include( 'includes.form.text', [
						'label' => 'Phone:',
						'name' => "admin[$adminIndex][facility_phone]",
						'size' => '10',
						'oldName' => "admin.$adminIndex.facility_phone",
						'sessionValue' => $admin->facility_phone,
					] )
				</fieldset>
		
				<br />
				
			</fieldset>
			
			<br />
		
			<input type="hidden" name="step" value="{{ $case->step }}"/>
			<input type="hidden" name="current_admin" value="{{ $adminIndex }}"/>
			
			<button type= "submit" name="action" value="previous">Previous</button>
			
			<button type="reset">Reset</button>
			
			<button type="submit" name="action" value="save">Save</button>
			
			<button type="submit" name="action" value="save_continue">Save and Continue</button>
			
		</form>
	</td>
</tr>

</table>

<div id="vaccine-dialog"></div>

<div class="modal"></div>

@endsection