File: /home/imensosw/public_html/imenso.co/demo/hmis/form-preview.php
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<title>HMIS - POC</title>
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<body>
<nav class="navbar border-bottom px-4 navbar-main">
<div class="container-fluid">
<img src="images/logo.svg" width="100">
<ul class="custom-ul">
<li class="nav-item">
<a href="javascript:;" onClick="changePage(0)" class="nav-link active">Admin</a>
</li>
</ul>
<ul class="nav nav-pills">
<li class="dropdown">
<a class="avtar" href="#" role="button" data-bs-toggle="dropdown" aria-expanded="false">
<span>J</span>
</a>
<ul class="dropdown-menu">
<li><a class="dropdown-item" href="#">Account</a></li>
<li><a class="dropdown-item" href="#">Logout</a></li>
</ul>
</li>
</ul>
</div>
</nav>
<div class="playground">
<div class="main-content">
<div class="mt-4 px-4">
<div class="container gutter">
<div class="d-flex justify-content-between align-items-center my-4">
<h3 class="mb-0 title">CoC Specific Elements</h3>
</div>
<div class="card" style="padding: 50px;">
<form>
<div class="mb-3">
<h4 class="form-field-title">C2 Moving On Assistance provided - PSH participants</h4>
</div>
<div class="mb-3">
<label for="" class="form-label">Date of Moving On Assistance</label>
<input type="text" class="form-control" id="">
</div>
<div class="mb-3">
<label for="" class="form-label">Moving On Assistance</label>
<select class="form-select">
<option>Select</option>
<option>Subsidized housing application assistance</option>
<option>Financial assistance for Moving On (e.g., security deposit, moving expenses)</option>
<option>Non-financial assistance for Moving On (e.g., housing navigation, transition support)</option>
<option>Housing referral/placement</option>
<option>Other (Please specify)</option>
</select>
</div>
<div class="text-end mt-5">
<a href="new-form.php" class="btn btn-secondary me-2">Cancel</a>
<button type="submit" class="btn btn-primary">Submit</button>
</div>
</form>
</div>
</div>
</div>
</div> <!--mc-grid-->
</div> <!-- main-content-->
</div> <!--playground-->
</body>
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