<?php if (!defined('BASEPATH')) exit('No direct script access allowed'); ?>
<script language="javascript" type="text/javascript">
	function ubah_saksi1(asal) {
		$('#saksi1').val(asal);
		if (asal == 1) {
			$('.saksi1_desa').show();
			$('.saksi1_luar_desa').hide();
		} else {
			$('.saksi1_desa').hide();
			$('.saksi1_luar_desa').show();
			$('#id_saksi1').val('*'); // Hapus $id_wanita
			submit_form_ambil_data();
		}
		$('input[name=anchor').val('saksi1');
	}

	function ubah_saksi2(asal) {
		$('#saksi2').val(asal);
		if (asal == 1) {
			$('.saksi2_desa').show();
			$('.saksi2_luar_desa').hide();
		} else {
			$('.saksi2_desa').hide();
			$('.saksi2_luar_desa').show();
			$('#id_saksi2').val('*'); // Hapus $id_wanita
			submit_form_ambil_data();
		}
		$('input[name=anchor').val('saksi2');
	}

	function ubah_pelapor(asal) {
		$('#pelapor').val(asal);
		if (asal == 1) {
			$('.pelapor_desa').show();
			$('.pelapor_luar_desa').hide();
		} else {
			$('.pelapor_desa').hide();
			$('.pelapor_luar_desa').show();
			$('#id_pelapor').val('*'); // Hapus $id_wanita
			submit_form_ambil_data();
		}
		$('input[name=anchor').val('pelapor');
	}

	function ubah_ibu(asal) {
		$('#ibu').val(asal);
		if (asal == 1) {
			$('.ibu_desa').show();
			$('.ibu_luar_desa').hide();
			$('#id_ibu').addClass('required');
		} else {
			$('.ibu_desa').hide();
			$('.ibu_luar_desa').show();
			$('#id_ibu').val('*'); // Hapus $id_wanita
			$('#id_ibu').removeClass('required');
			submit_form_ambil_data();
		}
		$('input[name=anchor').val('ibu');
	}

	function nomor_surat(nomor) {
		$('#nomor').val(nomor);
	}

	function submit_form_ambil_data() {
		$('input').removeClass('required');
		$('select').removeClass('required');
		$('#' + 'validasi').attr('action', '');
		$('#' + 'validasi').attr('target', '');
		$('#' + 'validasi').submit();
	}

	$('document').ready(function() {

		/* pergi ke bagian halaman sesudah mengisi warga desa */
		location.hash = "#" + $('input[name=anchor]').val();

		/* set nama_sex dari pilihan */
		$('input[name=nama_sex]').val($('#sex').find(':selected').text())

	});
</script>
<div class="content-wrapper">
	<?php $this->load->view("surat/form/breadcrumb.php"); ?>
	<section class="content">
		<div class="row">
			<div class="col-md-12">
				<div class="box box-info">
					<div class="box-header with-border">
						<a href="<?= site_url("surat") ?>" class="btn btn-social btn-flat btn-info btn-sm btn-sm visible-xs-block visible-sm-inline-block visible-md-inline-block visible-lg-inline-block" title="Kembali Ke Daftar Wilayah">
							<i class="fa fa-arrow-circle-left "></i>Kembali Ke Daftar Cetak Surat
						</a>
						<a href="#" class="btn btn-social btn-flat btn-primary btn-sm visible-xs-block visible-sm-inline-block visible-md-inline-block visible-lg-inline-block" title="Lihat Info Isian Surat" data-toggle="modal" data-target="#infoBox" data-title="Lihat Info Isian Surat">
							<i class="fa fa-info-circle"></i> Info Isian Surat
						</a>
					</div>
					<div class="box-body">
						<form id="validasi" action="<?= $form_action ?>" method="POST" target="_blank" class="form-surat form-horizontal">
							<input type="hidden" id="url_surat" name="url_surat" value="<?= $url ?>">
							<input type="hidden" id="url_remote" name="url_remote" value="<?= site_url('surat/nomor_surat_duplikat') ?>">
							<div class="col-md-12">
								<input name="anchor" type="hidden" value="<?= $anchor; ?>" />
								<?php if ($individu) : ?>
									<?php include("donjo-app/views/surat/form/konfirmasi_pemohon.php"); ?>
								<?php endif; ?>
								<?php include("donjo-app/views/surat/form/nomor_surat.php"); ?>
								<div class="form-group subtitle_head">
									<label class="col-sm-3 control-label" for="status">DATA IBU KANDUNG</label>
									<div class="btn-group col-sm-8" data-toggle="buttons">
										<label class="btn btn-info btn-flat btn-sm col-sm-4 col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (!empty($ibu)) : ?>active<?php endif ?>">
											<input id="ibu_1" type="radio" name="ibu" class="form-check-input" type="radio" value="1" <?php if (!empty($ibu)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_ibu(this.value);"> Dari Database Penduduk
										</label>
										<label id="label_ibu_2" class="btn btn-info btn-flat btn-sm col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (empty($ibu)) : ?>active<?php endif; ?>">
											<input id="ibu_2" type="radio" name="ibu" class="form-check-input" type="radio" value="2" <?php if (empty($ibu)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_ibu(this.value);"> Tidak Terdata
										</label>
									</div>
								</div>
								<div class="form-group ibu_desa" <?php if (empty($ibu)) : ?>style="display: none;" <?php endif; ?>>
									<label for="ibu_desa" class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA IBU DARI DATABASE </strong></label>
								</div>
								<div class="form-group ibu_desa" <?php if (empty($ibu)) : ?>style="display: none;" <?php endif; ?>>
									<div class="col-md-12">
										<div class="form-group">
											<label for="ibu_desa" class="col-sm-3 control-label"><strong>NIK / Nama Ibu </strong></label>
											<div class="col-sm-6 col-lg-4">
												<select class="form-control input-sm select2-nik-ajax" id="id_ibu" name="id_ibu" style="width:100%;" data-filter-sex="perempuan" data-url="<?= site_url('surat/list_penduduk_ajax') ?>" onchange="submit_form_ambil_data(this.id);">
													<?php if ($ibu) : ?>
														<option value="<?= $ibu['id'] ?>" selected><?= $ibu['nik'] . ' - ' . $ibu['nama'] ?></option>
													<?php endif; ?>
												</select>
											</div>
										</div>
									</div>
								</div>
								<?php if ($ibu) : ?>
									<?php //bagian info setelah terpilih
									$individu = $ibu;
									include("donjo-app/views/surat/form/konfirmasi_pemohon.php");
									?>
									<?php if (!empty($ayah)) : ?>
										<div class="form-group">
											<label for="ayah_desa" class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="padding-top:10px;padding-bottom:10px"><strong>DATA AYAH DARI DATABASE </strong></label>
										</div>
										<div class="form-group">
											<label for="ayah_desa" class="col-sm-3 control-label"><strong>NIK / Nama Ayah </strong></label>
											<div class="col-sm-8">
												<input class="form-control input-sm" type="text" placeholder="NIK / Nama Ayah" value="<?= $ayah['nik'] . ' / ' . $ayah['nama'] ?>" disabled>
											</div>
										</div>
										<?php
										$individu = $ayah;
										include("donjo-app/views/surat/form/konfirmasi_pemohon.php");
										?>
									<?php endif; ?>
								<?php endif; ?>
								<?php if (empty($ibu)) : ?>
									<div class="form-group ibu_luar_desa">
										<label for="ayah_desa" class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA IBU TIDAK TERDATA </strong></label>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="nama_ibu" class="col-sm-3 control-label">Nama Ibu</label>
										<div class="col-sm-8">
											<input class="form-control input-sm required" type="text" placeholder="Nama Ibu" name="nama_ibu" value="<?= $_SESSION['post']['nama_ibu'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="nik_ibu" class="col-sm-3 control-label">NIK Ibu</label>
										<div class="col-sm-8">
											<input class="form-control input-sm nik required" type="text" placeholder="NIK Ibu" name="nik_ibu" value="<?= $_SESSION['post']['nik_ibu'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="tempat_lahir_ibu" class="col-sm-3 control-label">Tempat / Tanggal Lahir / Umur</label>
										<div class="col-sm-3 col-lg-4">
											<input class="form-control input-sm" type="text" name="tempat_lahir_ibu" id="tempat_lahir_ibu" placeholder="Tempat Lahir Ibu" value="<?= $_SESSION['post']['tempat_lahir_ibu'] ?>">
										</div>
										<div class="col-sm-3 col-lg-2">
											<div class="input-group input-group-sm date">
												<div class="input-group-addon">
													<i class="fa fa-calendar"></i>
												</div>
												<input title="Pilih Tanggal" class="form-control input-sm required datepicker" name="tanggal_lahir_ibu" type="text" placeholder="Tgl. Lahir" value="<?= $_SESSION['post']['tanggal_lahir_ibu'] ?>" onchange="$('input[name=umur_ibu]').val(_calculateAge($(this).val()));" />
											</div>
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="umur_ibu" readonly="readonly" placeholder="Umur (Tahun)" type="text" value="<?= $_SESSION['post']['umur_ibu'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<input type="hidden" name="pekerjaanid_ibu">
										<label for="pekerjaanibu" class="col-sm-3 control-label"><strong>Pekerjaan</strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm" name="pekerjaanibu" id="pekerjaanibu" onchange="$('input[name=pekerjaanid_ibu]').val($(this).find(':selected').data('pekerjaanid'));">
												<option value="">-- Pekerjaan --</option>
												<?php foreach ($pekerjaan as $data) : ?>
													<option value="<?= $data['nama'] ?>" data-pekerjaanid="<?= $data['id'] ?>" <?php if ($data['nama'] == $_SESSION['post']['pekerjaanibu']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="ttl" class="col-sm-3 control-label">Tanggal Perkawinan</label>
										<div class="col-sm-3 col-lg-2">
											<div class="input-group input-group-sm date">
												<div class="input-group-addon">
													<i class="fa fa-calendar"></i>
												</div>
												<input title="Pilih Tanggal" class="form-control input-sm required datepicker" name="tanggalperkawinan_ibu" type="text" value="<?= $_SESSION['post']['tanggalperkawinan_ibu'] ?>" />
											</div>
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="alamat_ibu" class="col-sm-3 control-label">Alamat / RT / RW</label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="alamat_ibu" id="alamat_ibu" placeholder="Alamat Ibu" value="<?= $_SESSION['post']['alamat_ibu'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" type="text" name="rt_ibu" id="rt_ibu" placeholder="RT" value="<?= $_SESSION['post']['rt_ibu'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="rw_ibu" id="rw_ibu" type="text" placeholder="RW" value="<?= $_SESSION['post']['rw_ibu'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="alamat_ibu" class="col-sm-3 control-label">Desa / Kecamatan</label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="desaibu" id="desaibu" placeholder="Desa" value="<?= $_SESSION['post']['desaibu'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kecibu" id="kecibu" placeholder="Kecamatan" value="<?= $_SESSION['post']['kecibu'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="alamat_ibu" class="col-sm-3 control-label">Kabupaten / Provinsi</label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kabibu" id="kabibu" placeholder="Kabupaten" value="<?= $_SESSION['post']['kabibu'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="provinsiibu" id="provinsiibu" placeholder="Provinsi" value="<?= $_SESSION['post']['provinsiibu'] ?>">
										</div>
									</div>
								<?php endif; ?>
								<?php if (empty($ibu) or ($ibu and empty($ayah))) : ?>
									<div class="form-group ibu_luar_desa">
										<label for="ayah_desa" class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:10px;padding-top:10px;padding-bottom:10px"><strong>DATA AYAH TIDAK TERDATA </strong></label>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="nama_ayah" class="col-sm-3 control-label">Nama Ayah</label>
										<div class="col-sm-8">
											<input class="form-control input-sm required" type="text" placeholder="Nama Ayah" name="nama_ayah" value="<?= $_SESSION['post']['nama_ayah'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="nik_ayah" class="col-sm-3 control-label">NIK Ayah</label>
										<div class="col-sm-8">
											<input class="form-control input-sm nik required" type="text" placeholder="NIK Ayah" name="nik_ayah" value="<?= $_SESSION['post']['nik_ayah'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="tempat_lahir_ayah" class="col-sm-3 control-label">Tempat / Tanggal Lahir / Umur</label>
										<div class="col-sm-3 col-lg-4">
											<input class="form-control input-sm required" type="text" name="tempat_lahir_ayah" id="tempat_lahir_ayah" placeholder="Tempat Lahir" value="<?= $_SESSION['post']['tempat_lahir_ayah'] ?>">
										</div>
										<div class="col-sm-3 col-lg-2">
											<div class="input-group input-group-sm date">
												<div class="input-group-addon">
													<i class="fa fa-calendar"></i>
												</div>
												<input title="Pilih Tanggal" class="form-control input-sm required datepicker" name="tanggal_lahir_ayah" type="text" placeholder="Tgl. Lahir" value="<?= $_SESSION['post']['tempat_lahir_ayah'] ?>" onchange="$('input[name=umur_ayah]').val(_calculateAge($(this).val()));" />
											</div>
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm required" name="umur_ayah" readonly="readonly" placeholder="Umur (Tahun)" type="text" value="<?= $_SESSION['post']['umur_ayah'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<input type="hidden" name="pekerjaanid_ayah">
										<label for="pekerjaanayah" class="col-sm-3 control-label"><strong>Pekerjaan</strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm select2" name="pekerjaanayah" id="pekerjaanayah" style="width:100%;" onchange="$('input[name=pekerjaanid_ayah').val($(this).find(':selected').data('pekerjaanid'));">
												<option value="">-- Pekerjaan --</option>
												<?php foreach ($pekerjaan as $data) : ?>
													<option value="<?= $data['nama'] ?>" data-pekerjaanid="<?= $data['id'] ?>" <?php if ($data['nama'] == $_SESSION['post']['pekerjaanayah']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="alamat_ayah" class="col-sm-3 control-label">Alamat / RT / RW</label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="alamat_ayah" id="alamat_ayah" placeholder="Alamat" value="<?= $_SESSION['post']['alamat_ayah'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" type="text" name="rt_ayah" id="rt_ayah" placeholder="RT" value="<?= $_SESSION['post']['rt_ayah'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="rw_ayah" id="rw_ayah" type="text" placeholder="RW" value="<?= $_SESSION['post']['rw_ayah'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="alamat_ayah" class="col-sm-3 control-label">Desa / Kecamatan</label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="desaayah" id="desaayah" placeholder="Desa" value="<?= $_SESSION['post']['desaayah'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kecayah" id="kecayah" placeholder="Kecamatan" value="<?= $_SESSION['post']['kecayah'] ?>">
										</div>
									</div>
									<div class="form-group ibu_luar_desa">
										<label for="alamat_ayah" class="col-sm-3 control-label">Kabupaten / Provinsi</label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kabayah" id="kabayah" placeholder="Kabupaten" value="<?= $_SESSION['post']['kabayah'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="provinsiayah" id="provinsiayah" placeholder="Provinsi" value="<?= $_SESSION['post']['provinsiayah'] ?>">
										</div>
									</div>
								<?php endif; ?>
								<div class="form-group subtitle_head">
									<label class="col-sm-3 control-label" for="status">DATA KELAHIRAN </label>
								</div>
								<div class="form-group">
									<label class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA KELAHIRAN DARI DATABASE</strong></label>
								</div>
								<div class="form-group">
									<label for="ibu_desa" class="col-sm-3 control-label"><strong>NIK / Nama</strong></label>
									<div class="col-sm-6 col-lg-4">
										<select class="form-control  input-sm select2" id="id_bayi" name="id_bayi" style="width:100%;" onchange="submit_form_ambil_data(this.id);">
											<option value=""><?php if ($bayi) : ?>NIK : <?= $bayi['nik'] ?> - <?= $bayi['nama'] ?><?php else : ?>-- Cari NIK / Nama Penduduk --<?php endif; ?></option>
											<?php foreach ($anak as $data) : ?>
												<option value="<?= $data['id'] ?>">NIK : <?= $data['nik'] . " - " . $data['nama'] ?></option>
											<?php endforeach; ?>
										</select>
									</div>
								</div>
								<?php if ($bayi) : ?>
									<?php $individu = $bayi; ?>
									<?php include("donjo-app/views/surat/form/konfirmasi_pemohon.php"); ?>
								<?php endif; ?>
								<?php if (empty($bayi)) : ?>
									<div class="form-group bayi_luar_desa">
										<label for="nama_bayi" class="col-sm-3 control-label">Nama Yang Lahir</label>
										<div class="col-sm-8">
											<input type="text" name="nama_bayi" class="form-control input-sm required" placeholder="Nama Yang Lahir" value="<?= $_SESSION['post']['nama_bayi'] ?>"></input>
										</div>
									</div>
									<div class="form-group bayi_luar_desa">
										<label for="nik_bayi" class="col-sm-3 control-label">NIK Yang Lahir</label>
										<div class="col-sm-8">
											<input type="text" name="nik_bayi" class="form-control input-sm required" placeholder="NIK Yang Lahir" value="<?= $_SESSION['post']['nik_bayi'] ?>"></input>
											<p class="help-block small">*isi tanda - jika belum memiliki NIK</p>
										</div>
									</div>
									<div class="form-group bayi_luar_desa">
										<input type="hidden" name="nama_sex">
										<label for="nama_sex" class="col-sm-3 control-label">Jenis Kelamin</label>
										<div class="col-sm-4">
											<select name="sex" class="form-control input-sm required data_lahir" id="sex" onchange="$('input[name=nama_sex]').val($(this).find(':selected').text());">
												<option value="">Pilih Jenis Kelamin</option>
												<?php foreach ($sex as $data) : ?>
													<option value="<?= $data['id'] ?>" <?php if ($data['id'] == $_SESSION['post']['sex']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
								<?php endif; ?>
								<div class="form-group">
									<label for="ttl" class="col-sm-3 control-label">Hari / Tanggal / Jam</label>
									<div class="col-sm-3 col-lg-4">
										<input id="hari" readonly="readonly" class="form-control input-sm data_lahir hari" type="text" placeholder="Hari Lahir" name="hari" value="<?= $_SESSION['post']['hari'] ?>">
									</div>
									<div class="col-sm-3 col-lg-2">
										<div class="input-group input-group-sm date">
											<div class="input-group-addon">
												<i class="fa fa-calendar"></i>
											</div>
											<input title="Pilih Tanggal" class="form-control input-sm data_lahir data_hari required datepicker" placeholder="Tgl. Lahir" name="tanggallahir" type="text" value="<?= $_SESSION['post']['tanggallahir'] ?>" />
										</div>
									</div>
									<div class="col-sm-2">
										<div class="input-group input-group-sm date">
											<div class="input-group-addon">
												<i class="fa fa-clock-o"></i>
											</div>
											<input class="form-control input-sm data_lahir required" placeholder="Jam Lahir" name="waktu_lahir" id="jammenit_1" type="text" value="<?= $_SESSION['post']['waktu_lahir'] ?>" />
										</div>
									</div>
								</div>
								<div class="form-group">
									<label for="nama_sex" class="col-sm-3 control-label">Tempat Dilahirkan</label>
									<div class="col-sm-4">
										<select name="tempat_dilahirkan" class="form-control input-sm required data_lahir" id="tempat_dilahirkan">
											<option value="">Pilih Tempat Dilahirkan</option>
											<?php foreach ($tempat_dilahirkan as $id => $nama) : ?>
												<option value="<?= $id ?>" <?php if ($_SESSION['post']['tempat_dilahirkan'] == $id) : ?>selected<?php endif; ?>><?= $nama ?></option>
											<?php endforeach; ?>
										</select>
									</div>
								</div>
								<div class="form-group">
									<label for="tempatlahir" class="col-sm-3 control-label">Tempat Kelahiran</label>
									<div class="col-sm-8">
										<input name="tempatlahir" type="text" class="form-control input-sm required data_lahir" id="tempatlahir" placeholder="Tempat kelahiran" value="<?= $_SESSION['post']['tempatlahir'] ?>" />
										<p class="help-block small">*(Nama Kota/Kabupaten)</p>
									</div>
								</div>
								<div class="form-group">
									<label for="jenis_kelahiran" class="col-sm-3 control-label">Jenis Kelahiran</label>
									<div class="col-sm-4">
										<select name="jenis_kelahiran" class="form-control input-sm required data_lahir" id="jenis_kelahiran" readonly>
											<option value="">Pilih Jenis Kelahiran</option>
											<?php foreach ($jenis_kelahiran as $id => $nama) : ?>
												<option value="<?= $id ?>" <?php if ($_SESSION['post']['jenis_kelahiran'] == $id) : ?>selected<?php endif; ?>><?= $nama ?></option>
											<?php endforeach; ?>
										</select>
									</div>
								</div>
								<div class="form-group">
									<label for="kelahiran_anak_ke" class="col-sm-3 control-label">Kelahiran Anak Ke</label>
									<div class="col-sm-2">
										<input type="text" name="kelahiran_anak_ke" class="form-control input-sm data_lahir required" placeholder="Anak Ke" value="<?= $_SESSION['post']['kelahiran_anak_ke'] ?>"></input>
									</div>
								</div>
								<div class="form-group">
									<label for="penolong_kelahiran" class="col-sm-3 control-label">Penolong Kelahiran</label>
									<div class="col-sm-4">
										<select name="penolong_kelahiran" class="form-control input-sm required data_lahir" id="jenis_kelahiran">
											<option value="">Pilih Penolong Kelahiran</option>
											<?php foreach ($penolong_kelahiran as $id => $nama) : ?>
												<option value="<?= $id ?>" <?php if ($_SESSION['post']['penolong_kelahiran'] == $id) : ?>selected<?php endif; ?>><?= $nama ?></option>
											<?php endforeach; ?>
										</select>
									</div>
								</div>
								<div class="form-group">
									<label for="berat_lahir" class="col-sm-3 control-label">Berat Bayi</label>
									<div class="col-sm-2">
										<div class="input-group input-group-sm">
											<input class="form-control input-sm data_lahir" placeholder="Berat Bayi" name="berat_lahir" id="input_group" type="text" value="<?= $_SESSION['post']['berat_lahir'] ?>" />
											<div class="input-group-addon" style="width:40px;">gram</div>
										</div>
									</div>
								</div>
								<div class="form-group">
									<label for="panjang_lahir" class="col-sm-3 control-label">Panjang Bayi</label>
									<div class="col-sm-2">
										<div class="input-group input-group-sm">
											<input class="form-control input-sm data_lahir" placeholder="Panjang Bayi" name="panjang_lahir" id="input_group" type="text" value="<?= $_SESSION['post']['panjang_lahir'] ?>" />
											<div class="input-group-addon" style="width:40px;">cm</div>
										</div>
									</div>
								</div>
								<div class="form-group subtitle_head">
									<label class="col-sm-3 control-label" for="status">PELAPOR </label>
									<div class="btn-group col-sm-8" data-toggle="buttons">
										<label class="btn btn-info btn-flat btn-sm col-sm-4 col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (!empty($pelapor)) : ?>active<?php endif ?>">
											<input id="pelapor_1" type="radio" name="pelapor" class="form-check-input" type="radio" value="1" <?php if (!empty($pelapor)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_pelapor(this.value);"> Warga Desa
										</label>
										<label id="label_pelapor_2" class="btn btn-info btn-flat btn-sm col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (empty($pelapor)) : ?>active<?php endif; ?>">
											<input id="pelapor_2" type="radio" name="pelapor" class="form-check-input" type="radio" value="2" <?php if (empty($pelapor)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_pelapor(this.value);"> Warga Luar Desa
										</label>
									</div>
								</div>
								<div class="form-group pelapor_desa" <?php if (empty($pelapor)) : ?>style="display: none;" <?php endif; ?>>
									<label class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA PELAPOR DARI DATABASE</strong></label>
								</div>
								<div class="form-group pelapor_desa" <?php if (empty($pelapor)) : ?>style="display: none;" <?php endif; ?>>
									<label for="ibu_desa" class="col-sm-3 control-label"><strong>NIK / Nama</strong></label>
									<div class="col-sm-6 col-lg-4">
										<select class="form-control  input-sm select2-nik-ajax" id="id_pelapor" name="id_pelapor" style="width:100%;" data-url="<?= site_url('surat/list_penduduk_ajax') ?>" onchange="submit_form_ambil_data(this.id);">
											<?php if ($pelapor) : ?>
												<option value="<?= $pelapor['id'] ?>" selected><?= $pelapor['nik'] . ' - ' . $pelapor['nama'] ?></option>
											<?php endif; ?>
										</select>
									</div>
								</div>
								<?php if ($pelapor) : ?>
									<?php $individu = $pelapor; ?>
									<?php include("donjo-app/views/surat/form/konfirmasi_pemohon.php"); ?>
								<?php endif; ?>
								<?php if (empty($pelapor)) : ?>
									<div class="form-group pelapor_luar_desa">
										<label for="ayah_desa" class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA PELAPOR LUAR DESA </strong></label>
									</div>
									<div class="form-group pelapor_luar_desa">
										<label for="nama_pelapor" class="col-sm-3 control-label">Nama Pelapor</label>
										<div class="col-sm-8">
											<input class="form-control input-sm required" type="text" placeholder="Nama Pelapor" name="nama_pelapor" value="<?= $_SESSION['post']['nama_pelapor'] ?>">
										</div>
									</div>
									<div class="form-group pelapor_luar_desa">
										<label for="nik_pelapor" class="col-sm-3 control-label">NIK Pelapor</label>
										<div class="col-sm-8">
											<input class="form-control input-sm required" type="text" placeholder="NIK Pelapor" name="nik_pelapor" value="<?= $_SESSION['post']['nik_pelapor'] ?>">
										</div>
									</div>
									<div class="form-group pelapor_luar_desa">
										<label for="tempat_lahir_pelapor" class="col-sm-3 control-label">Tempat / Tanggal Lahir / Umur</label>
										<div class="col-sm-3 col-lg-4">
											<input class="form-control input-sm" type="text" name="tempat_lahir_pelapor" id="tempat_lahir_pelapor" placeholder="Tempat Lahir Pelapor" value="<?= $_SESSION['post']['tempat_lahir_pelapor'] ?>">
										</div>
										<div class="col-sm-3 col-lg-2">
											<div class="input-group input-group-sm date">
												<div class="input-group-addon">
													<i class="fa fa-calendar"></i>
												</div>
												<input title="Pilih Tanggal" class="form-control input-sm required datepicker" name="tanggal_lahir_pelapor" type="text" placeholder="Tgl. Lahir" value="<?= $_SESSION['post']['tanggal_lahir_pelapor'] ?>" onchange="$('input[name=umur_pelapor]').val(_calculateAge($(this).val()));" />
											</div>
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="umur_pelapor" readonly="readonly" placeholder="Umur (Tahun)" type="text" value="<?= $_SESSION['post']['umur_pelapor'] ?>">
										</div>
									</div>
									<div class="form-group pelapor_luar_desa">
										<label for="pekerjaanpelapor" class="col-sm-3 control-label"><strong>Jenis Kelamin </strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm" name="jkpelapor" id="jkpelapor">
												<option value="">-- Jenis Kelamin --</option>
												<?php foreach ($sex as $data) : ?>
													<option value="<?= $data['id'] ?>" <?php if ($data['id'] == $_SESSION['post']['jkpelapor']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group pelapor_luar_desa">
										<input type="hidden" name="pekerjaanid_pelapor">
										<label for="pekerjaanpelapor" class="col-sm-3 control-label"><strong>Pekerjaan </strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm" name="pekerjaanpelapor" id="pekerjaanpelapor" onchange="$('input[name=pekerjaanid_pelapor]').val($(this).find(':selected').data('pekerjaanid'));">
												<option value="">-- Pekerjaan --</option>
												<?php foreach ($pekerjaan as $data) : ?>
													<option value="<?= $data['nama'] ?>" data-pekerjaanid="<?= $data['id'] ?>" <?php if ($data['nama'] == $_SESSION['post']['pekerjaanpelapor']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group pelapor_luar_desa">
										<label for="alamat_pelapor" class="col-sm-3 control-label">Alamat / RT / RW </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="alamat_pelapor" id="alamat_pelapor" placeholder="Alamat Pelapor" value="<?= $_SESSION['post']['alamat_pelapor'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" type="text" name="rt_pelapor" id="rt_pelapor" placeholder="RT" value="<?= $_SESSION['post']['rt_pelapor'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="rw_pelapor" id="rw_pelapor" type="text" placeholder="RW" value="<?= $_SESSION['post']['rw_pelapor'] ?>">
										</div>
									</div>
									<div class="form-group pelapor_luar_desa">
										<label for="alamat_pelapor" class="col-sm-3 control-label">Desa / Kecamatan </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="desapelapor" id="desapelapor" placeholder="Desa" value="<?= $_SESSION['post']['desapelapor'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kecpelapor" id="kecpelapor" placeholder="Kecamatan" value="<?= $_SESSION['post']['kecpelapor'] ?>">
										</div>
									</div>
									<div class="form-group pelapor_luar_desa">
										<label for="alamat_pelapor" class="col-sm-3 control-label">Kabupaten / Provinsi </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kabpelapor" id="kabpelapor" placeholder="Kabupaten" value="<?= $_SESSION['post']['kabpelapor'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="provinsipelapor" id="provinsipelapor" placeholder="Provinsi" value="<?= $_SESSION['post']['provinsipelapor'] ?>">
										</div>
									</div>
								<?php endif; ?>
								<div class="form-group">
									<label for="hubungan_pelapor" class="col-sm-3 control-label">Hubungan Pelapor dengan Bayi</label>
									<div class="col-sm-8">
										<input class="form-control input-sm required" type="text" placeholder="Hubungan Pelapor dengan Bayi" name="hubungan_pelapor" value="<?= $_SESSION['post']['hubungan_pelapor'] ?>">
									</div>
								</div>
								<div class="form-group subtitle_head">
									<label class="col-sm-3 control-label" for="status">SAKSI 1 </label>
									<div class="btn-group col-sm-8" data-toggle="buttons">
										<label class="btn btn-info btn-flat btn-sm col-sm-4 col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (!empty($saksi1)) : ?>active<?php endif ?>">
											<input id="saksi1_1" type="radio" name="saksi1" class="form-check-input" type="radio" value="1" <?php if (!empty($saksi1)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_saksi1(this.value);"> Warga Desa
										</label>
										<label id="label_saksi1_2" class="btn btn-info btn-flat btn-sm col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (empty($saksi1)) : ?>active<?php endif; ?>">
											<input id="saksi1_2" type="radio" name="saksi1" class="form-check-input" type="radio" value="2" <?php if (empty($saksi1)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_saksi1(this.value);"> Warga Luar Desa
										</label>
									</div>
								</div>
								<div class="form-group saksi1_desa" <?php if (empty($saksi1)) : ?>style="display: none;" <?php endif; ?>>
									<label class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA SAKSI 1 DARI DATABASE</strong></label>
								</div>
								<div class="form-group saksi1_desa" <?php if (empty($saksi1)) : ?>style="display: none;" <?php endif; ?>>
									<label for="saksi1_desa" class="col-sm-3 control-label"><strong>NIK / Nama</strong></label>
									<div class="col-sm-6 col-lg-4">
										<select class="form-control input-sm select2-nik-ajax" id="id_saksi1" name="id_saksi1" style="width:100%;" data-url="<?= site_url('surat/list_penduduk_ajax') ?>" onchange="submit_form_ambil_data(this.id);">
											<?php if ($saksi1) : ?>
												<option value="<?= $saksi1['id'] ?>" selected><?= $saksi1['nik'] . ' - ' . $saksi1['nama'] ?></option>
											<?php endif; ?>
										</select>
									</div>
								</div>
								<?php if ($saksi1) : ?>
									<?php $individu = $saksi1; ?>
									<?php include("donjo-app/views/surat/form/konfirmasi_pemohon.php"); ?>
								<?php endif; ?>
								<?php if (empty($saksi1)) : ?>
									<div class="form-group saksi1_luar_desa">
										<label for="ayah_desa" class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA SAKSI 1 LUAR DESA </strong></label>
									</div>
									<div class="form-group saksi1_luar_desa">
										<label for="nama_saksi1" class="col-sm-3 control-label">Nama Saksi</label>
										<div class="col-sm-8">
											<input class="form-control input-sm required" type="text" placeholder="Nama Saksi" name="nama_saksi1" value="<?= $_SESSION['post']['nama_saksi1'] ?>">
										</div>
									</div>
									<div class="form-group saksi1_luar_desa">
										<label for="nik_saksi1" class="col-sm-3 control-label">NIK Saksi</label>
										<div class="col-sm-8">
											<input class="form-control input-sm nik required" type="text" placeholder="NIK Saksi" name="nik_saksi1" value="<?= $_SESSION['post']['nik_saksi1'] ?>">
										</div>
									</div>
									<div class="form-group saksi1_luar_desa">
										<label for="tempat_lahir_saksi1" class="col-sm-3 control-label">Tempat / Tanggal Lahir / Umur</label>
										<div class="col-sm-3 col-lg-4">
											<input class="form-control input-sm" type="text" name="tempat_lahir_saksi1" id="tempat_lahir_saksi1" placeholder="Tempat Lahir Saksi" value="<?= $_SESSION['post']['tempat_lahir_saksi1'] ?>">
										</div>
										<div class="col-sm-3 col-lg-2">
											<div class="input-group input-group-sm date">
												<div class="input-group-addon">
													<i class="fa fa-calendar"></i>
												</div>
												<input title="Pilih Tanggal" class="form-control input-sm required datepicker" name="tanggal_lahir_saksi1" type="text" placeholder="Tgl. Lahir" value="<?= $_SESSION['post']['tanggal_lahir_saksi1'] ?>" onchange="$('input[name=umur_saksi1]').val(_calculateAge($(this).val()));" />
											</div>
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="umur_saksi1" readonly="readonly" placeholder="Umur (Tahun)" type="text" value="<?= $_SESSION['post']['umur_saksi1'] ?>">
										</div>
									</div>
									<div class="form-group saksi1_luar_desa">
										<label for="pekerjaanpelapor" class="col-sm-3 control-label"><strong>Jenis Kelamin </strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm" name="jksaksi1" id="jksaksi1">
												<option value="">-- Jenis Kelamin --</option>
												<?php foreach ($sex as $data) : ?>
													<option value="<?= $data['id'] ?>" <?php if ($data['id'] == $_SESSION['post']['jksaksi1']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group saksi1_luar_desa">
										<input type="hidden" name="pekerjaanid_saksi1">
										<label for="pekerjaansaksi1" class="col-sm-3 control-label"><strong>Pekerjaan </strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm" name="pekerjaansaksi1" id="pekerjaansaksi1" onchange="$('input[name=pekerjaanid_saksi1]').val($(this).find(':selected').data('pekerjaanid'));">
												<option value="">-- Pekerjaan --</option>
												<?php foreach ($pekerjaan as $data) : ?>
													<option value="<?= $data['nama'] ?>" data-pekerjaanid="<?= $data['id'] ?>" <?php if ($data['nama'] == $_SESSION['post']['pekerjaansaksi1']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group saksi1_luar_desa">
										<label for="alamat_saksi1" class="col-sm-3 control-label">Alamat / RT / RW </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="alamat_saksi1" id="alamat_saksi1" placeholder="Alamat Saksi" value="<?= $_SESSION['post']['alamat_saksi1'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" type="text" name="rt_saksi1" id="rt_saksi1" placeholder="RT" value="<?= $_SESSION['post']['rt_saksi1'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="rw_saksi1" id="rw_saksi1" type="text" placeholder="RW" value="<?= $_SESSION['post']['rw_saksi1'] ?>">
										</div>
									</div>
									<div class="form-group saksi1_luar_desa">
										<label for="alamat_saksi1" class="col-sm-3 control-label">Desa / Kecamatan </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="desasaksi1" id="desasaksi1" placeholder="Desa" value="<?= $_SESSION['post']['desasaksi1'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kecsaksi1" id="kecsaksi1" placeholder="Kecamatan" value="<?= $_SESSION['post']['kecsaksi1'] ?>">
										</div>
									</div>
									<div class="form-group saksi1_luar_desa">
										<label for="alamat_saksi1" class="col-sm-3 control-label">Kabupaten / Provinsi </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kabsaksi1" id="kabsaksi1" placeholder="Kabupaten" value="<?= $_SESSION['post']['kabsaksi1'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="provinsisaksi1" id="provinsisaksi1" placeholder="Provinsi" value="<?= $_SESSION['post']['provinsisaksi1'] ?>">
										</div>
									</div>
								<?php endif; ?>
								<div class="form-group subtitle_head">
									<label class="col-sm-3 control-label" for="status">SAKSI 2 </label>
									<div class="btn-group col-sm-8" data-toggle="buttons">
										<label class="btn btn-info btn-flat btn-sm col-sm-4 col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (!empty($saksi2)) : ?>active<?php endif ?>">
											<input id="saksi2_1" type="radio" name="saksi2" class="form-check-input" type="radio" value="1" <?php if (!empty($saksi2)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_saksi2(this.value);"> Warga Desa
										</label>
										<label id="label_saksi2_2" class="btn btn-info btn-flat btn-sm col-sm-4 col-md-4 col-lg-3 form-check-label <?php if (empty($saksi2)) : ?>active<?php endif; ?>">
											<input id="saksi2_2" type="radio" name="saksi2" class="form-check-input" type="radio" value="2" <?php if (empty($saksi2)) : ?>checked<?php endif; ?> autocomplete="off" onchange="ubah_saksi2(this.value);"> Warga Luar Desa
										</label>
									</div>
								</div>
								<div class="form-group saksi2_desa" <?php if (empty($saksi2)) : ?>style="display: none;" <?php endif; ?>>
									<label class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA SAKSI 2 DARI DATABASE</strong></label>
								</div>
								<div class="form-group saksi2_desa" <?php if (empty($saksi2)) : ?>style="display: none;" <?php endif; ?>>
									<label for="saksi2_desa" class="col-sm-3 control-label"><strong>NIK / Nama</strong></label>
									<div class="col-sm-6 col-lg-4">
										<select class="form-control input-sm select2-nik-ajax" id="id_saksi2" name="id_saksi2" style="width:100%;" data-url="<?= site_url('surat/list_penduduk_ajax') ?>" onchange="submit_form_ambil_data(this.id);">
											<?php if ($saksi2) : ?>
												<option value="<?= $saksi2['id'] ?>" selected><?= $saksi2['nik'] . ' - ' . $saksi2['nama'] ?></option>
											<?php endif; ?>
										</select>
									</div>
								</div>
								<?php if ($saksi2) : ?>
									<?php $individu = $saksi2; ?>
									<?php include("donjo-app/views/surat/form/konfirmasi_pemohon.php"); ?>
								<?php endif; ?>
								<?php if (empty($saksi2)) : ?>
									<div class="form-group saksi2_luar_desa">
										<label for="ayah_desa" class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:-10px;padding-top:10px;padding-bottom:10px"><strong>DATA SAKSI 2 LUAR DESA </strong></label>
									</div>
									<div class="form-group saksi2_luar_desa">
										<label for="nama_saksi2" class="col-sm-3 control-label">Nama Saksi</label>
										<div class="col-sm-8">
											<input class="form-control input-sm required" type="text" placeholder="Nama Saksi" name="nama_saksi2" value="<?= $_SESSION['post']['nama_saksi2'] ?>">
										</div>
									</div>
									<div class="form-group saksi2_luar_desa">
										<label for="nik_saksi2" class="col-sm-3 control-label">NIK Saksi</label>
										<div class="col-sm-8">
											<input class="form-control input-sm nik required" type="text" placeholder="NIK Saksi" name="nik_saksi2" value="<?= $_SESSION['post']['nik_saksi2'] ?>">
										</div>
									</div>
									<div class="form-group saksi2_luar_desa">
										<label for="tempat_lahir_saksi2" class="col-sm-3 control-label">Tempat / Tanggal Lahir / Umur</label>
										<div class="col-sm-3 col-lg-4">
											<input class="form-control input-sm" type="text" name="tempat_lahir_saksi2" id="tempat_lahir_saksi2" placeholder="Tempat Lahir Saksi" value="<?= $_SESSION['post']['tempat_lahir_saksi2'] ?>">
										</div>
										<div class="col-sm-3 col-lg-2">
											<div class="input-group input-group-sm date">
												<div class="input-group-addon">
													<i class="fa fa-calendar"></i>
												</div>
												<input title="Pilih Tanggal" class="form-control input-sm datepicker required" name="tanggal_lahir_saksi2" type="text" placeholder="Tgl. Lahir" value="<?= $_SESSION['post']['tanggal_lahir_saksi2'] ?>" onchange="$('input[name=umur_saksi2]').val(_calculateAge($(this).val()));" />
											</div>
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="umur_saksi2" readonly="readonly" placeholder="Umur (Tahun)" type="text" value="<?= $_SESSION['post']['umur_saksi2'] ?>">
										</div>
									</div>
									<div class="form-group saksi2_luar_desa">
										<label for="pekerjaanpelapor" class="col-sm-3 control-label"><strong>Jenis Kelamin </strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm" name="jksaksi2" id="jksaksi2">
												<option value="">-- Jenis Kelamin --</option>
												<?php foreach ($sex as $data) : ?>
													<option value="<?= $data['id'] ?>" <?php if ($data['id'] == $_SESSION['post']['jksaksi2']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group saksi2_luar_desa">
										<input type="hidden" name="pekerjaanid_saksi2">
										<label for="pekerjaansaksi2" class="col-sm-3 control-label"><strong>Pekerjaan </strong></label>
										<div class="col-sm-4">
											<select class="form-control input-sm" name="pekerjaansaksi2" id="pekerjaansaksi2" onchange="$('input[name=pekerjaanid_saksi2]').val($(this).find(':selected').data('pekerjaanid'));">
												<option value="">-- Pekerjaan --</option>
												<?php foreach ($pekerjaan as $data) : ?>
													<option value="<?= $data['nama'] ?>" data-pekerjaanid="<?= $data['id'] ?>" <?php if ($data['nama'] == $_SESSION['post']['pekerjaansaksi2']) : ?>selected<?php endif; ?>><?= $data['nama'] ?></option>
												<?php endforeach; ?>
											</select>
										</div>
									</div>
									<div class="form-group saksi2_luar_desa">
										<label for="alamat_saksi2" class="col-sm-3 control-label">Alamat / RT / RW </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="alamat_saksi2" id="alamat_saksi2" placeholder="Alamat Saksi" value="<?= $_SESSION['post']['alamat_saksi2'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" type="text" name="rt_saksi2" id="rt_saksi2" placeholder="RT" value="<?= $_SESSION['post']['rt_saksi2'] ?>">
										</div>
										<div class="col-sm-2">
											<input class="form-control input-sm" name="rw_saksi2" id="rw_saksi2" type="text" placeholder="RW" value="<?= $_SESSION['post']['rw_saksi2'] ?>">
										</div>
									</div>
									<div class="form-group saksi2_luar_desa">
										<label for="alamat_saksi2" class="col-sm-3 control-label">Desa / Kecamatan </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="desasaksi2" id="desasaksi2" placeholder="Desa" value="<?= $_SESSION['post']['desasaksi2'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kecsaksi2" id="kecsaksi2" placeholder="Kecamatan" value="<?= $_SESSION['post']['kecsaksi2'] ?>">
										</div>
									</div>
									<div class="form-group saksi2_luar_desa">
										<label for="alamat_saksi2" class="col-sm-3 control-label">Kabupaten / Provinsi </label>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="kabsaksi2" id="kabsaksi2" placeholder="Kabupaten" value="<?= $_SESSION['post']['kabsaksi2'] ?>">
										</div>
										<div class="col-sm-4">
											<input class="form-control input-sm" type="text" name="provinsisaksi2" id="provinsisaksi2" placeholder="Provinsi" value="<?= $_SESSION['post']['provinsisaksi2'] ?>">
										</div>
									</div>
								<?php endif; ?>
								<div class="form-group">
									<label class="col-xs-12 col-sm-3 col-lg-3 control-label bg-maroon" style="margin-top:10px;padding-top:10px;padding-bottom:10px"><strong>PENANDA TANGAN</strong></label>
								</div>
								<div class="form-group">
									<label class="col-sm-3 control-label">Lokasi Disdukcapil <?= ucwords($this->setting->sebutan_kabupaten) ?></label>
									<div class="col-sm-8">
										<input class="form-control input-sm required" type="text" name="lokasi_disdukcapil" id="lokasi_disdukcapil" placeholder="Lokasi Disdukcapil" value="<?= $_SESSION['post']['lokasi_disdukcapil'] ?>">
									</div>
								</div>
								<?php include("donjo-app/views/surat/form/_pamong.php"); ?>
							</div>
						</form>
					</div>
					<?php include("donjo-app/views/surat/form/tombol_cetak.php"); ?>
				</div>
				<div class='modal fade' id='infoBox' tabindex='-1' role='dialog' aria-labelledby='myModalLabel' aria-hidden='true'>
					<div class='modal-dialog'>
						<div class='modal-content'>
							<div class='modal-header btn-default'>
								<button type='button' class='close' data-dismiss='modal' aria-hidden='true'>&times;</button>
								<h4 class='modal-title' id='myModalLabel'><i class='fa fa-info-circle'></i>&nbsp;&nbsp;Info Isian Surat</h4>
							</div>
							<div class='modal-body small'>
								<h5><strong>Form ini menghasilkan:</strong></h5>
								<ol>
									<li>Surat Keterangan Kelahiran</li>
									<li>Permohonan Penyelesaian Akta Kelahiran</li>
									<li>Lampiran F-2.01 SURAT KETERANGAN KELAHIRAN bagi warga yang akan dibuatkan akta kelahiran</li>
								</ol>
								<p>Pastikan semua biodata orang tua warga yang lahir, pelapor dan saksi-saksi sudah lengkap sebelum mencetak surat dan lampiran. </p>
								<p>Untuk melengkapi data itu, ubah data warga yang bersangkutan di form isian penduduk di modul Penduduk.</p>
								<p>PERHATIAN: setelah Export Doc, pengisian/perubahan data kelahiran akan direkam ke database penduduk.</p>
							</div>
							<div class='modal-footer btn-default'>
								<button type="button" class="btn btn-social btn-flat btn-danger btn-sm" data-dismiss="modal"><i class='fa fa-sign-out'></i> Tutup</button>
							</div>
						</div>
					</div>
				</div>
			</div>
		</div>
	</section>
</div>