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<script>
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$(function() {
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$( ".txt_PDdate" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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$('.schedule_time').timepicker({
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timeOnlyTitle: 'Choose Time',
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timeText:'Time',
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hourText:'Hour',
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minuteText:'Minute',
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secondText:'Second',
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currentText:'Now',
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closeText:'Done'
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});
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});
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</script>
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<div style="display: block; width: 100%; text-align: center; font-family: Arial; font-size: 14px; font-weight: bold; padding-top: 10px; padding-bottom: 5px;">
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ECG; 28 Day Cycle 1 Dosing Day 26
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</div>
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<div style="clear: both; height: 20px; width: 100%"></div>
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<label>Rate: </label><input type="text" name="txt_rate" /> <label>Intervals: </label>
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PR<input type="checkbox" name="chk_opt1" />
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QRS<input type="checkbox" name="chk_opt2" />
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QT<input type="checkbox" name="chk_opt3" />
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QTc<input type="checkbox" name="chk_opt4" />
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<br/><br/>
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<label>Machine Interpretation: </label><br/>
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<textarea cols="50" rows="5"></textarea>
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<br/>
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<label>Does the Investigator agree or disagree with this interpretation?</label><br/>
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<input type="radio" name="rbn_opt" />Agree
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<input type="radio" name="rbn_opt" />Disagree*
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<br/><br/>
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<label>*If disagrees, alternative interpretation <u>must</u> be provided below:</label><br/>
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<textarea cols="50" rows="5"></textarea>
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<br/>
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<label>Were findings clinically significant?</label><br/>
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<input type="radio" name="rbn_opt" />Yes**
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<input type="radio" name="rbn_opt" />No
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<br/><label>**Report on AE page.</label>
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<br/><br/>
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<table border="1" style="width: 650px">
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<thead>
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<tr>
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<th>Date<br/>DD/MM/YYYY</th>
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<th>Interval<br/>Hoour</th>
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<th>Select<br/>Appropiate</th>
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<th>Target</th>
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<th>Actual Time</th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td><input type="text" name="txt_date1" class="txt_PDdate" style="width: 78px"/></td>
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<td>Immediately<br/>(Pre-Dose)</td>
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<td><input type="text" name="txt_dateRep" value="" style="width: 100px"/></td>
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<td><input type="text" name="txt_dateRep" value="" style="width: 100px"/></td>
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<td><input type="text" name="txt_dateRep" style="width: 100px" class="schedule_time" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00" /></td>
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</tr>
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|
<tr>
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|
<td style="background-color: #A6A6A6"></td>
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|
<td>End of<br/>Infusion(hr. 4)</td>
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|
|
<td><input type="text" name="txt_dateRep" value="" style="width: 100px"/></td>
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|
|
<td><input type="text" name="txt_date1" style="width: 100px"/></td>
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|
|
<td><input type="text" name="txt_dateRep" style="width: 100px" class="schedule_time" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00" /></td>
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|
</tr>
|
|
|
</tbody>
|
|
|
</table>
|
|
|
<div class="tool_buttons">
|
|
|
<input type="submit" value="save" id="btn_save" name="btn_save">
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|
|
<input type="reset" value="clear" id="btn_clear" name="btn_clear">
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</div>
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