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formOtherItems.php
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formOtherItems.php
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<?php
session_start();
$username = $_POST['username'];
$pw1 = $_POST['password1'];
$pw2 = $_POST['password2'];
?>
<html >
<head>
<meta charset="UTF-8">
<title>Sign Up</title>
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/normalize/5.0.0/normalize.min.css">
<link rel="stylesheet" href="css/style.css">
</head>
<body>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Sign Up Form</title>
<link rel="stylesheet" href="css/normalize.css">
<link href='https://fonts.googleapis.com/css?family=Nunito:400,300' rel='stylesheet' type='text/css'>
<link rel="stylesheet" href="css/main.css">
</head>
<body>
<form action="saveUserInfo.php" method="post">
<h1>Sign Up</h1>
<input class="form-control" type="hidden" name="username" value="<?php echo $username;?>">
<input class="form-control" type="hidden" name="password1" value="<?php echo $pw1;?>">
<input class="form-control" type="hidden" name="password2" value="<?php echo $pw2;?>">
<input type="hidden" name="consent" value=1 checked>
<fieldset>
<legend><span class="number">1</span>Your basic info</legend>
<label>Age*:</label>
<input type = "text" name = "age">
<!--<select class="ui dropdown" name="age">
<option value=""></option>
<option value="0">18-25</option>
<option value="1">26-35</option>
<option value="2">36-45</option>
<option value="3">46-55</option>
<option value="4">56-65</option>
<option value="5">66+</option>
</select> -->
<label>Gender:</label>
<select class="ui dropdown" name="gender">
<option value=""></option>
<option value="male"> Male </option>
<option value="female"> Female </option>
</select>
<label>Education:</label>
<select class="ui dropdown" name="education">
<option value=""></option>
<option value="Doctoral">Doctoral</option>
<option value="Master">Masters</option>
<option value="Professional">Professional</option>
<option value="Bachelor">Bachelor</option>
<option value="Associate">Associate</option>
<option value="High School">High School</option>
<option value="Below High School">Below High School</option>
<option value="Other">Other</option>
</select>
<label>Major:</label>
<select class="ui dropdown" name="Major">
<option value=""></option>
<option value="Health Care Administration">Health Care Administration</option>
<option value="Medical Records Administration">Medical Records Administration</option>
<option value="Nursing">Nursing</option>
<option value="Health Sciences">Health Sciences</option>
<option value="Business Administration">Business Administration</option>
<option value="Information Technology">Information Technology</option>
<option value="Public Health">Public Health</option>
<option value="Other">Other</option>
</select>
</fieldset>
<fieldset>
<legend><span class="number">2</span>Your Job</legend>
<label>Job Title:</label>
<select class="ui dropdown" name="Job_Title">
<option value=""></option>
<option value="Information Technology Specialist">Information Technology Specialist</option>
<option value="Program Manager">Program Manager</option>
<option value="Chief Executive Officer (CEO)">Chief Executive Officer (CEO)</option>
<option value="Chief Medical Information Officer">Chief Medical Information Officer</option>
<option value="Chief Medical Officer">Chief Medical Officer</option>
<option value="Chief Nursing Officer">Chief Nursing Officer</option>
<option value="Chief Operating Officer">Chief Operating Officer</option>
<option value="Telehealth Supervisor">Telehealth Supervisor</option>
<option value="Consultant">Consultant</option>
<option value="Other">Other</option>
</select>
<label>Work Experience in Information Security and Privacy:</label>
<select class="ui dropdown" name="Work_Experience">
<option value=""></option>
<option value="0">0-2 years</option>
<option value="1">3-5 years</option>
<option value="2">6-10 years</option>
<option value="3">11-15 years</option>
<option value="4">16-25 years</option>
<option value="5">26+ years</option>
</select>
<label>Type of Organization:</label>
<select class="ui dropdown" name="Organization_Type">
<option value=""></option>
<option value="Hospital">Hospital</option>
<option value="Hospital Network">Hospital Network</option>
<option value="Physician Group Practice">Physician Group Practice</option>
<option value="Group or Ambulatory Surgical Center">Group or Ambulatory Surgical Center</option>
<option value="Health Maintenance Organization (HMO)">Health Maintenance Organization (HMO)</option>
<option value="Managed Care Organization (MCO)">Managed Care Organization (MCO)</option>
<option value="Independent Practice Association (IPA)">Independent Practice Association (IPA)</option>
<option value="Physician Sponsored Network (PSN)">Physician Sponsored Network (PSN)</option>
<option value="Preferred Provider Organization (PPO)">Preferred Provider Organization (PPO)</option>
<option value="Other">Other</option>
</select>
<label>Organization Name:</label>
<input type = "text" name = "Organization_Name">
<label>Size of Organization:</label>
<select class="ui dropdown" name="Organization_Size">
<option value=""></option>
<option value="1-100">1-100</option>
<option value="101-200">101-200</option>
<option value="201-300">201-300</option>
<option value="301-400">301-400</option>
<option value="401-500">401-500</option>
<option value="501+">501+</option>
</select>
<label>Years of Using Telehealth in Practice:</label>
<select class="ui dropdown" name="Telehealth_Use_Years">
<option value=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6+</option>
</select>
<label>Number of People in IT Team in your organization:</label>
<input class="form-control" type="checkbox" name="IT_Team_Number" value ="0"> <label class = "light"> 0 </label><br>
<input type="checkbox" name="IT_Team_Number" value="0-3"> <label class = "light"> 0-3 </label> <br>
<input type="checkbox" name="IT_Team_Number" value="4-10"> <label class = "light"> 4-10 </label> <br>
<input type="checkbox" name="IT_Team_Number" value="11-20"> <label class = "light"> 11-20 </label> <br>
<input type="checkbox" name="IT_Team_Number" value="21-50"> <label class = "light"> 21-50 </label> <br>
<input type="checkbox" name="IT_Team_Number" value="51-100"> <label class = "light"> 51-100 </label> <br>
<input type="checkbox" name="IT_Team_Number" value="101-200"> <label class = "light"> 101-200 </label> <br>
<input type="checkbox" name="IT_Team_Number" value="201-500"> <label class = "light"> 201-500 </label> <br>
<input type="checkbox" name="IT_Team_Number" value="501+"> <label class = "light"> 501+ </label>
<br> </br>
<label>Number of IT Persons Familiar with Information Security:</label>
<input class="form-control" type="checkbox" name="IT_Persons_Number" value ="0"> <label class = "light"> 0 </label> <br>
<input type="checkbox" name="IT_Persons_Number" value="0-3"> <label class = "light"> 0-3 </label> <br>
<input type="checkbox" name="IT_Persons_Number" value="4-10"> <label class = "light"> 4-10 </label> <br>
<input type="checkbox" name="IT_Persons_Number" value="11-20"> <label class = "light"> 11-20 </label> <br>
<input type="checkbox" name="IT_Persons_Number" value="21-50"> <label class = "light"> 21-50 </label><br>
<input type="checkbox" name="IT_Persons_Number" value="51-100"> <label class = "light"> 51-100 </label> <br>
<input type="checkbox" name="IT_Persons_Number" value="101-200"> <label class = "light"> 101-200 </label> <br>
<input type="checkbox" name="IT_Persons_Number" value="201-500"> <label class = "light"> 201-500 </label> <br>
<input type="checkbox" name="IT_Persons_Number" value="501+"> <label class = "light"> 501+ </label> <br>
</fieldset>
<button type="submit">Sign Up</button>
</form>
</body>
</html>
</body>
</html>