ESH/form_o.php

<div class="modal fade" id="form_genaration_0" role="dialog"
	aria-hidden="true">

	<div class="modal-dialog" id="modal-dialog1">

		<div class="modal-content">



			<div class="modal-header">

				<h5 class='modal-title'>Form O</h5>

				<button type="button" class="close" id="form_close"
					data-dismiss="modal" aria-label="Close">

					<span aria-hidden="true">&times;</span>

				</button>

			</div>



			<div id="pdfModal">

				<form class="form" id="form_0_pdf" name="form_0_pdf" method="post"
					target="_blank">

					<div class="panel-body" id="form_0_pdf_body">

					<?php 



					error_reporting(0);



					$query = "select company_logo,image_type from company_profile where company_id =5 ";

					//echo $query;

					$result = mysqli_query($conn,$query);

					$row = mysqli_fetch_array($result);

					@extract($row);?>





						<table width="100%" class="tbl1">



							<tr>

								<td rowspan="4"><img
									src="data:image/jpeg;base64,<?php  echo base64_encode( $row['company_logo'] )?>"
									style="display: block; width: 134px; height: 60px;" /></td>



								<td rowspan="4">MAIHAR IU</td>

								<td>Department</td>

								<td>OCCUPATIONAL HEALTH CENTRE</td>

							</tr>



							<tr>

								<td>Document No.</td>

								<td id="doc_no_o">F-MED-07</td>

							</tr>



							<tr>

								<td>Revision</td>

								<td>0.0</td>

							</tr>



							<tr>

								<td>Implementation Date</td>



								<td>01.04.2016</td>

							</tr>

							<tr>

								<td align="center" colspan="4">Form O</td>

							</tr>



						</table>





						<div
							style="border-right: 1px solid black; border-bottom: 1px solid black; border-left: 1px solid black; margin-top: -20px">

							<br> <br> <br>

							<div
								style="margin-top: 10px; margin-left: 10px; margin-right: 10px">

								<table width="100%" class="tbl3" id="form_header">



									<tr>

										<td colspan="2" align="center">REPORT OF MEDICAL EXAMINATION

											UNDER RULE 29-B</td>

									</tr>

									<tr>

										<td colspan="2" align="center">(In Triplicate)</td>

									</tr>







								</table>







							</div>



							<div
								style="margin-top: 10px; margin-left: 10px; margin-right: 10px">
								<input type="hidden" name="medical_exam_id_O"
									id="medical_exam_id_O"><input type="hidden" name="form_type_O"
									id="form_type_O">

								<table width="100%" class="tbl3" id="table_body_form_o">





									<tr>

										<td><p contenteditable="true">(a) is medically fit for any
												employment in mines</p>
										</td>



									</tr>



									<tr>

										<td><p contenteditable="true">(b) is suffering
												from.............................and medically unfit for</p>



										</td>

									</tr>



									<tr>

										<td><p contenteditable="true">(i) any employment in mines; or

											</p>
										</td>

									</tr>





									<tr>

										<td><p contenteditable="true">(ii)any employment below ground
												; or</p>
										</td>



									</tr>





									<tr>

										<td><p contenteditable="true">(iii) any employment or
												work..............................</p>
										</td>



									</tr>



									<tr>

										<td><p contenteditable="true">(c) is suffering
												from....................and should get this disability
												cured/controlled and should be again examined within a
												period of....................Months. He will appear for
												reexamination with the result of test of
												.................and the option of............specialist
												from.........He may be permitted/not permitted to carry on
												his duties during this period.</p>
										</td>

















									</tr>









								</table>





							</div>
                       

                         
							<div style="margin-top: 0px">

								<table width="100%" class="tbl3">

									<tr>

										
										
										<td align="right"><span align="right"
											style="margin-right: 83px" class="profile-picture"
											id="profile-picture1"> </span>
										<p style="margin-right: 80px">Digital Signature of examining
												authority</p></td>

									</tr>
                                  
					<tr>
										<td style="margin-right: 83px" align="right"><span  id="doctor_name_id"  style="margin-right: 95px">  </span></td>
										</tr>
										<tr>
										<td style="margin-right: 83px" align="right" ><span id="qualification_id" style="margin-right: 52px">  </span></td>
										</tr>
										<tr>
										<td  style="margin-right: 83px" align="right" ><span id="registration_no_id" style="margin-right: 192px">  </span></td>
										</tr>
                                    


									<tr>

										
										
										<td align="right"><span style="margin-right: 232px;">Place:</span></td>

									</tr>



									<tr>

										
										
										<td align="right"><p style="margin-right: 14px;">

												Date: Name and designation in block letter</br> </br>



											</p></td>



									</tr>
									</br>
									  </br>
									   </br>
									    </br>
									     </br>

									
										  <div style="width:200px;height:150px;border:1px solid #000;margin-left:40px;margin-top: -80px;">Photograph</div>
                                       


								</table>

                          

							</div>



						</div>
				
				</form>

			</div>



			<div class="modal-footer">

				<div class="form-group">







					<button type="button" class="btn btn-default"
						onclick="form_generation_for_pdf($('#form_type_O').val())">

						<span class="glyphicon glyphicon-floppy-save">Open PDF</span>

					</button>



				</div>

			</div>

















		</div>



		<form id="form_pdf" name="form_pdf" target="_blank" action=""
			method="POST">

			<input type="hidden" name="htmlText" id="htmlText" />

		</form>