{% extends 'base.html.twig' %}

{% block title %}Input for NHM Budget{% endblock %}

{% block content %}
	<div class="kt-subheader kt-grid__item"></div>

	<form class="kt-form" method="POST" autocomplete="off">
		<div class="kt-container kt-grid__item kt-grid__item--fluid">
			<div class="kt-portlet kt-portlet--mobile">
				<div class="kt-portlet__head kt-portlet__head--lg">
					<div class="kt-portlet__head-label">
						<h3 class="kt-portlet__head-title">Input for NHM Budget</h3>
					</div>

					<div class="kt-portlet__head-toolbar">
						<div class="kt-portlet__head-wrapper">
							<a href="{{ path('gaps_hr_nhm') }}" class="btn btn-clean btn-icon-sm mr-2"><i class="la la-long-arrow-left"></i>Back</a>
							<a href="{{ app.request.uri }}" class="btn btn-secondary btn-bold mr-2">Reset</a>
							<button class="btn btn-primary btn-bold">Submit</button>
						</div>
					</div>
				</div>

				<div class="kt-portlet__body">
					<div class="col-12">
						<div class="row">
							<div class="col-6">
								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Level</label>

									<div class="col-8">
										<select name="level" class="form-control">
											<option value="">Select Level</option>
											<option value="State">State</option>
											<option value="Region">Region</option>
											<option value="District">District</option>
											<option value="Sub District">Sub District</option>
											<option value="DH">DH</option>
											<option value="DTC">DTC</option>
											<option value="DLC">DLC</option>
											<option value="CHC">CHC</option>
											<option value="PHC">PHC</option>
											<option value="UHC">UHC</option>
											<option value="HSC">HSC</option>
										</select>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Budget Type</label>

									<div class="col-8">
										<select name="budget_type" class="form-control">
											<option value="">Select Budget Type</option>
											<option value="All">All</option>
											<option value="New">New</option>
											<option value="Continue">Continue</option>
										</select>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Head</label>

									<div class="col-8">
										<select name="head" class="form-control">
											<option value="">Select Head</option>
											<option value="Service delivery - Facility based">Service delivery - Facility based</option>
											<option value="Service delivery - Community Intervention">Service delivery - Community Intervention</option>
											<option value="Community Intervention">Community Intervention</option>
											<option value="Untied Fund">Untied Fund</option>
											<option value="Infrastructure">Infrastructure</option>
											<option value="Procurement">Procurement</option>
											<option value="Referral Transport">Referral Transport</option>
											<option value="Human Resource">Human Resource</option>
											<option value="Training &amp; Capacity Building">Training &amp; Capacity Building</option>
											<option value="Review, Research, Surveillance &amp; Surveys">Review, Research, Surveillance &amp; Surveys</option>
											<option value="IEC / BCC">IEC / BCC</option>
											<option value="Printing">Printing</option>
											<option value="Quality Assurance">Quality Assurance</option>
											<option value="Drug Warehousing and Logistics">Drug Warehousing and Logistics</option>
											<option value="PPP">PPP</option>
											<option value="Program Management">Program Management</option>
											<option value="IT Initiatives for strengthening Service Delivery">IT Initiatives for strengthening Service Delivery</option>
											<option value="Innovations (if any)">Innovations (if any)</option>
											<option value="New Program">New Program</option>
											<option value="Total Budget">Total Budget</option>
										</select>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Subhead</label>

									<div class="col-8">
										<select name="subhead" class="form-control">
											<option value="">Select Subhead</option>
											<option value="Service Delivery - Facility Based">Service Delivery - Facility Based</option>
											<option value="Service Delivery - Community Intervention">Service Delivery - Community Intervention</option>
											<option value="Beneficiary Compensation / Allowances">Beneficiary Compensation / Allowances</option>
											<option value="Beneficiary Compensation under Janani Suraksha Yojana (JSY)">Beneficiary Compensation under Janani Suraksha Yojana (JSY)</option>
											<option value="Beneficiary Compensation under FP Services">Beneficiary Compensation under FP Services</option>
											<option value="Others">Others</option>
											<option value="Operating Expenses">Operating Expenses</option>
											<option value="Service Delivery - Community Based">Service Delivery - Community Based</option>
											<option value="Mobile Units">Mobile Units</option>
											<option value="Recurring / Operational Cost">Recurring / Operational Cost</option>
											<option value="Outreach Activities">Outreach Activities</option>
											<option value="Community Interventions">Community Interventions</option>
											<option value="ASHA Activities">ASHA Activities</option>
											<option value="Performance Incentive / Other Incentive to ASHAs">Performance Incentive / Other Incentive to ASHAs</option>
											<option value="Selection &amp; Training of ASHA">Selection &amp; Training of ASHA</option>
											<option value="Miscellaneous ASHA Costs">Miscellaneous ASHA Costs</option>
											<option value="Other Community Interventions">Other Community Interventions</option>
											<option value="Panchayati Raj Institutions (PRIs)">Panchayati Raj Institutions (PRIs)</option>
											<option value="Untied Fund">Untied Fund</option>
											<option value="Infrastructure">Infrastructure</option>
											<option value="Upgradation of existing facilities">Upgradation of existing facilities</option>
											<option value="New Constructions">New Constructions</option>
											<option value="Other Construction / Civil Works">Other Construction / Civil Works</option>
											<option value="Procurement">Procurement</option>
											<option value="Procurement of Equipment">Procurement of Equipment</option>
											<option value="Procurement of Drugs and Supplies">Procurement of Drugs and Supplies</option>
											<option value="Procurement of Other Drugs and Supplies">Procurement of Other Drugs and Supplies</option>
											<option value="National Free Diagnostic Services">National Free Diagnostic Services</option>
											<option value="Procurement (Others)">Procurement (Others)</option>
											<option value="Referral Transport">Referral Transport</option>
											<option value="Service Delivery - Human Resource">Service Delivery - Human Resource</option>
											<option value="Human Resources">Human Resources</option>
											<option value="Annual increment for all the existing positions">Annual increment for all the existing positions</option>
											<option value="EPF">EPF</option>
											<option value="Incentives and Allowances">Incentives and Allowances</option>
											<option value="Training &amp; Capacity Building">Training &amp; Capacity Building</option>
											<option value="Setting Up &amp; Strengthening of Skill Lab / Other Training Centres">Setting Up &amp; Strengthening of Skill Lab / Other Training Centres</option>
											<option value="HR for Skill Lab / Training Institutes / SIHFW">HR for Skill Lab / Training Institutes / SIHFW</option>
											<option value="Trainings">Trainings</option>
											<option value="Review, Research, Surveillance &amp; Surveys">Review, Research, Surveillance &amp; Surveys</option>
											<option value="Reviews">Reviews</option>
											<option value="Research &amp; Surveys">Research &amp; Surveys</option>
											<option value="Surveillance">Surveillance</option>
											<option value="Other Recurring cost">Other Recurring cost</option>
											<option value="IEC / BCC">IEC / BCC</option>
											<option value="Printing">Printing</option>
											<option value="Quality Assurance">Quality Assurance</option>
											<option value="Kayakalp">Kayakalp</option>
											<option value="Any other Activity">Any other Activity</option>
											<option value="Drug Warehousing and Logistics">Drug Warehousing and Logistics</option>
											<option value="Drug Warehousing">Drug Warehousing</option>
											<option value="Logistics and Supply Chain">Logistics and Supply Chain</option>
											<option value="PPP">PPP</option>
											<option value="Programme Management">Programme Management</option>
											<option value="Planning Activities">Planning Activities</option>
											<option value="Monitoring &amp; Data Management">Monitoring &amp; Data Management</option>
											<option value="HMIS &amp; MCTS">HMIS &amp; MCTS</option>
											<option value="Any Other PM Activities">Any Other PM Activities</option>
											<option value="IT Initiatives for strengthening Service Delivery">IT Initiatives for strengthening Service Delivery</option>
											<option value="Innovations">Innovations</option>
										</select>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Service</label>

									<div class="col-8">
										<select name="minor_head" class="form-control">
											<option value="">Select Service</option>
											<option value="Service 1">Service 1</option>
											<option value="Service 2">Service 2</option>
											<option value="Service 3">Service 3</option>
										</select>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">As per IPHS</label>

									<div class="col-8">
										<span class="form-text">100</span>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Existing</label>

									<div class="col-8">
										<span class="form-text">90</span>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Gaps</label>

									<div class="col-8">
										<span class="form-text">10</span>
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Particulars</label>

									<div class="col-8">
										<input type="text" name="particulars" class="form-control" maxlength="20" onkeydown="return /[0-9a-zA-Z ]/i.test(event.key)">
									</div>
								</div>
							</div>

							<div class="col-6">
								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Pool</label>

									<div class="col-8">
										<input type="text" name="pool" class="form-control" maxlength="20" onkeydown="return /[0-9a-zA-Z ]/i.test(event.key)">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Main Program Division</label>

									<div class="col-8">
										<input type="text" name="main_program_division" class="form-control" maxlength="50" onkeydown="return /[0-9a-zA-Z ]/i.test(event.key)">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Program</label>

									<div class="col-8">
										<input type="text" name="program" class="form-control" maxlength="50" onkeydown="return /[0-9a-zA-Z ]/i.test(event.key)">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Unit of Measure</label>

									<div class="col-8">
										<input type="text" name="unit_of_measure" class="form-control unit_of_measure" maxlength="10" oninput="this.value = this.value.replace(/[^0-9]/g, '')">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Unit Cost (Rs.)</label>

									<div class="col-8">
										<input type="text" name="unit_cost" class="form-control unit_cost" maxlength="10" oninput="this.value = this.value.replace(/[^0-9]/g, '')">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Quantity / Target</label>

									<div class="col-8">
										<input type="text" name="quantity_target" class="form-control quantity_target" maxlength="10" oninput="this.value = this.value.replace(/[^0-9]/g, '')">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Budget (Rs. Lakhs)</label>

									<div class="col-8">
										<input type="text" name="budget" class="form-control budget" maxlength="10" oninput="this.value = this.value.replace(/[^0-9]/g, '')">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Justification</label>

									<div class="col-8">
										<input type="text" name="justification" class="form-control" maxlength="50" onkeydown="return /[0-9a-zA-Z ]/i.test(event.key)">
									</div>
								</div>

								<div class="form-group row">
									<label class="col-4 col-form-label font-weight-bold">Program Officer</label>

									<div class="col-8">
										<input type="text" name="program_officer" class="form-control" maxlength="50" onkeydown="return /[0-9a-zA-Z ]/i.test(event.key)">
									</div>
								</div>
							</div>
						</div>
					</div>
				</div>
			</div>
		</div>
	</form>
{% endblock %}