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intake-en.html
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<!DOCTYPE html>
<!--[if lt IE 9]><html class="no-js lt-ie9" lang="en" dir="ltr"><![endif]-->
<!--[if gt IE 8]><!-->
<html class="no-js" lang="en" dir="ltr">
<!--<![endif]-->
<head>
<meta charset="utf-8">
<!-- Web Experience Toolkit (WET) / Boîte à outils de l'expérience Web (BOEW) wet-boew.github.io/wet-boew/License-en.html / wet-boew.github.io/wet-boew/Licence-fr.html -->
<title>Intake Form - ESDC / IT Accessibility office</title>
<meta content="width=device-width,initial-scale=1" name="viewport">
<!-- Meta data -->
<meta name="description"
content="Intake form for the IT Accessibility Office at ESDC">
<!-- Meta data-->
<!-- Load closure template scripts -->
<script src="https://ssl-templates.services.gc.ca/rn/cls/wet/gcweb/cdts/compiled/soyutils.js"></script>
<script src="https://ssl-templates.services.gc.ca/rn/cls/wet/gcweb/cdts/compiled/wet-en.js"></script>
<!-- Write closure template -->
<script src="https://bati-itao.github.io/scripts/refTop.min.js"></script>
</head>
<body vocab="https://schema.org/" typeof="WebPage">
<div id="def-top">
</div>
<script>
var defTop = document.getElementById("def-top");
defTop.outerHTML = wet.builder.appTop({
"appName": [{
"text": "ESDC / IT Accessibility office",
"href": "https://bati-itao.github.io/"
}],
"breadcrumbs" : [{
"title": "Home",
"href" : "https://bati-itao.github.io/"
}],
"lngLinks": [{
"lang": "en",
"href": "./intake-fr.html",
"text": "Français"
}],
"menuPath": "https://bati-itao.github.io/ajax/menu-en.html"
});
</script>
<main property="mainContentOfPage" class="container">
<h1 property="name" id="wb-cont">Intake Form</h1>
<div class="wb-frmvld">
<form action="#" id="a11y-survey" method="post">
<input name="ID" type="hidden" value="accessibility_coaching" />
<input name="ESDCEmailForm" type="hidden" value="Y" />
<input name="whichSurvey" type="hidden" value="Intake">
<div class="wb-fieldflow" data-wb-fieldflow='{"noForm": true}'>
<p>Select a Service Category</p>
<ul>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "Adaptive Technology Assessment"},{"action": "toggle", "toggle": "#toggle1 , #clientInformation", "live": true}]'>Adaptive Technology Assessment</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "IT Accessibility Coaching, Awareness and Curriculum"},{"action": "toggle", "toggle": "#toggle2 , #clientInformation", "live": true}]'>IT Accessibility Coaching, Awareness and Curriculum</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "Accessibility Compliance Project"},{"action": "toggle", "toggle": "#toggle3 , #clientInformation", "live": true}]'>Accessibility Compliance Project</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "Web Information and communications technology (ICT) Assessment"},{"action": "toggle", "toggle": "#toggle4 , #clientInformation", "live": true}]'>Web Information and communications technology (ICT) Assessment</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "COTS Information and communications technology (ICT) Assessment"},{"action": "toggle", "toggle": "#toggle5 , #clientInformation", "live": true}]'>COTS Information and communications technology (ICT) Assessment</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "Document Accessibility Review"},{"action": "toggle", "toggle": "#toggle6 , #clientInformation", "live": true}]'>Document Accessibility Review</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "Procurement and General Advice on Accessible ICT"},{"action": "toggle", "toggle": "#toggle7 , #clientInformation", "live": true}]'>Procurement and General Advice on Accessible ICT</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "Follow up on previous request"},{"action": "toggle", "toggle": "#followUp , #generalRequest , #clientInformation", "live": true}]'>Follow up on previous request</li>
<li data-wb-fieldflow='[{"action": "query", "name": "selectService", "value": "Other"},{"action": "toggle", "toggle": "#clientInformation , #generalRequest", "live": true}]'>Other</li>
</ul>
</div>
<div class="form-group mrgn-tp-lg hidden" id="generalRequest">
<label for="request">Describe you request</label>
<textarea class="full-width expand form-control" name="request" id="request"></textarea>
</div>
<div class="form-group mrgn-tp-lg hidden" id="followUp">
<label for="caseNumber">Case number</label>
<textarea class="full-width expand form-control" name="caseNumber" id="caseNumber"></textarea>
</div>
<fieldset id="toggle1" class="hidden">
<legend>Adaptive Technology Assessment</legend>
<div class="form-group mrgn-tp-lg">
<label for="DisabilityType">Disability Type</label>
<select class="form-control" name="DisabilityType" id="DisabilityType">
<option disabled="disabled" selected="selected" aria-hidden="true">Disability Type</option>
<option value="Low Vision">Low Vision</option>
<option value="Blindness">Blindness</option>
<option value="Mobility / Dexterity">Mobility / Dexterity</option>
<option value="Hearing Impairment">Hearing Impairment</option>
<option value="Cognition">Cognition</option>
<option value="Other">Other</option>
</select>
</div>
<div class="form-group mrgn-tp-lg">
<label for="ataServiceType">Service Type</label>
<select class="form-control" name="ataServiceType" id="ataServiceType">
<option disabled="disabled" selected="selected">Make your selection...</option>
<option value="Assessment">Assessment</option>
<option value="Support">Support</option>
<option value="Loan Bank">Loan Bank</option>
</select>
</div>
<div class="form-group"></div>
</fieldset>
<fieldset id="toggle2" class="hidden">
<legend>IT Accessibility Coaching, Awareness and Curriculum</legend>
<div class="form-group mrgn-tp-lg">
<label for="awarenessServiceType">Service Type</label>
<select class="form-control" name="awarenessServiceType" id="awarenessServiceType">
<option disabled="disabled" selected="selected">Make your selection...</option>
<option value="Coaching half day for managers and up">Coaching half day for managers and up</option>
<option value="Coaching full day for developers">Coaching full day for developers</option>
<option value="Awareness">Awareness</option>
<option value="Curriculum">Curriculum</option>
</select>
</div>
</fieldset>
<fieldset id="toggle3" class="hidden">
<legend>Accessibility Compliance Project</legend>
<div class="form-group mrgn-tp-lg">
<label for="ProjectType">Project Type</label>
<select class="form-control" name="ProjectType" id="ProjectType">
<option disabled="disabled" selected="selected">Make your selection...</option>
<option value="New">New</option>
<option value="On-going">On-going</option>
</select>
</div>
</fieldset>
<fieldset id="toggle4" class="hidden">
<legend>Web Information and communications technology (ICT) Assessment</legend>
<div class="form-group mrgn-tp-lg">
<label for="Websitecategory">Website category</label>
<select class="form-control" name="Websitecategory" id="Websitecategory">
<option disabled="disabled" selected="selected">Make your selection...</option>
<option value="Internal">Internal</option>
<option value="External">External</option>
</select>
</div>
<div class="form-group mrgn-tp-lg">
<label for="url">URL of the site</label>
<input class="form-control full-width" id="url" name="url" type="url" />
</div>
<div class="form-group mrgn-tp-lg">
<label for="username">User Name</label>
<input class="form-control full-width" id="username" name="username" type="text" />
</div>
<div class="form-group mrgn-tp-lg">
<label for="password">Password</label>
<input class="form-control full-width" id="password" name="password" type="text" />
</div>
</fieldset>
<fieldset id="toggle5" class="hidden">
<legend>COTS Information and communications technology (ICT) Assessment</legend>
<div class="form-group mrgn-tp-lg">
<label for="ProductName">Product Name</label>
<input class="form-control full-width" id="ProductName" name="ProductName" type="text" />
</div>
<div class="form-group mrgn-tp-lg">
<label for="cots_url">URL of the site</label>
<input class="form-control full-width" id="cots_url" name="cots_url" type="url" />
</div>
<div class="form-group mrgn-tp-lg">
<label for="cots_username">User Name</label>
<input class="form-control full-width" id="cots_username" name="cots_username" type="text" />
</div>
<div class="form-group mrgn-tp-lg">
<label for="cots_password">Password</label>
<input class="form-control full-width" id="cots_password" name="cots_password" type="text" />
</div>
</fieldset>
<fieldset id="toggle6" class="hidden">
<legend>Document Accessibility Review</legend>
<div class="form-group mrgn-tp-lg">
<label for="documentType">Document Type</label>
<input aria-describedby="docSend" class="form-control full-width" id="documentType" name="documentType" type="text" />
<div id="docSend" class="alert alert-warning mrgn-tp-lg">
<p>You will be contacted by one of our assessors for your documents once they are ready to be reviewed.</p>
</div>
</div>
</fieldset>
<fieldset id="toggle7" class="hidden">
<legend>Procurement and General Advice on Accessible Information and Communication Technology (ICT)</legend>
<div class="form-group mrgn-tp-lg">
<label for="ICT_Type">Information and communications technology (ICT) Type</label>
<select class="form-control" name="ICT_Type" id="ICT_Type">
<option disabled="disabled" selected="selected">Make your selection...</option>
<option value="Software">Software</option>
<option value="Hardware">Hardware</option>
<option value="Information and communications technology (ICT) with Two Way Communication">Information and communications technology (ICT) with Two Way Communication</option>
<option value="Relay and Emergency Services">Relay and Emergency Services</option>
</select>
</div>
</fieldset>
<div id="clientInformation" class="hidden">
<fieldset>
<legend>Client Information</legend>
<div class="form-group">
<label for="LastName">Last Name</label>
<input class="form-control full-width" id="LastName" autocomplete="family-name" name="LastName" type="text" />
</div>
<div class="form-group">
<label for="FirstName">First Name</label>
<input class="form-control full-width" id="FirstName" autocomplete="given-name" name="FirstName" type="text" />
</div>
<div class="form-group">
<label for="PhoneNumber">Phone Number (including area code)</label>
<input class="form-control" id="PhoneNumber" placeholder="333-333-3333" name="PhoneNumber" autocomplete="tel" data-rule-phoneUS="true" type="tel" />
</div>
<div class="form-group">
<label for="EmailAddress">Email Address</label>
<input class="form-control full-width" id="EmailAddress" name="EmailAddress" autocomplete="email" type="email" />
</div>
<fieldset>
<legend>Dealine</legend>
<div class="row">
<div class="form-group col-md-3">
<label for="year">Year (YYYY)</label>
<input type="number" class="form-control" id="year" name="year" />
</div>
<div class="form-group col-md-3">
<label for="month">Month</label>
<input type="number" class="form-control" id="month" name="month" />
</div>
<div class="form-group col-md-3">
<label for="day">Day</label>
<input type="number" class="form-control" id="day" name="day" />
</div>
</div>
</fieldset>
</fieldset>
<div class="form-group mrgn-tp-lg">
<label for="additionalInfo">Any additional information</label>
<textarea name="additionalInfo" id="additionalInfo" class="form-control full-width expand"></textarea>
</div>
</div>
<input type="submit" value="Submit" class="btn btn-primary btn-lg" />
<input type="reset" value="Reset" class="btn btn-primary btn-lg">
</form>
</div>
<div id="def-preFooter"></div>
<script src="https://bati-itao.github.io/scripts/preFooter.min.js"></script>
</main>
<div id="def-footer"></div>
<script src="https://bati-itao.github.io/scripts/appFooter.min.js"></script>
<script src="https://bati-itao.github.io/scripts/refFooter.min.js"></script>
<script src="https://bati-itao.github.io/scripts/bati-itao.min.js"></script>
</body>
</html>