{"_id":"676301241116ab199918db34","title":"VA_VISN16_v3","name":"vaVisn16V3","path":"vavisn16v3","type":"form","display":"form","tags":[],"access":[{"type":"read_all","roles":["5f9ae327f1b65926a66350f3","5f9ae327f1b65921a76350f4"]},{"type":"update_all","roles":["5f9ae327f1b65926a66350f3"]}],"submissionAccess":[{"type":"create_all","roles":["5f9ae327f1b65926a66350f3","5f9ae327f1b65921a76350f4"]}],"owner":"5f9acba5f1b659b9e06350e4","components":[{"label":"Top of Form","columns":[{"components":[{"label":"<font color=\"red\">authorizationToken</font>","key":"authorizationToken","type":"hidden","input":true,"tableView":false,"hideOnChildrenHidden":true,"width":12}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"<font color=\"red\">agencyFormId</font>","key":"agencyFormId","type":"hidden","input":true,"tableView":false,"hideOnChildrenHidden":true,"width":12}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"min/max","persistent":"client-only","calculateServer":true,"trigger":{"init":true,"server":true},"dataSrc":"url","fetch":{"url":"{{ config.PAYGOV_ENV }}/public/api/v1/minmaxamount/{{ data.agencyFormId }}","method":"get","headers":[{"key":"X-Paygov-Authorization-Token","value":"{{ data.authorizationToken }}"}],"forwardHeaders":true,"authenticate":false},"key":"minMax","type":"datasource","input":true,"tableView":false,"hideOnChildrenHidden":true,"width":12}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"Company Profile","persistent":"client-only","calculateServer":true,"trigger":{"init":true,"server":true},"dataSrc":"url","fetch":{"url":"{{ config.PAYGOV_ENV }}/public/api/v1/companyprofile/{{ data.agencyFormId }}","method":"get","headers":[{"key":"X-Paygov-Authorization-Token","value":"{{ data.authorizationToken }}"}],"forwardHeaders":true,"authenticate":false},"key":"CompanyDataFromPaygov","type":"datasource","input":true,"tableView":false,"validate":{"multiple":true},"hideOnChildrenHidden":true,"keyModified":true,"multiple":true,"width":12}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2}],"autoAdjust":true,"hideOnChildrenHidden":true,"key":"columns3","type":"columns","input":false,"tableView":false,"lockKey":true,"source":"5eac84259b53ff041c170ee7","isNew":true},{"label":"HTML","tag":"img","attrs":[{"attr":"src","value":"{{ config.STATIC_ASSETS_ENV }}/VAVISN/images/VISN16_SIG_transparent_black_text.png"},{"attr":"alt","value":"VA Capital Health Care Network VISN 16"},{"attr":"title","value":"VA Capital Health Care Network VISN 16"},{"attr":"style","value":"max-width: 500px;"}],"refreshOnChange":false,"key":"html1","type":"htmlelement","input":false,"tableView":false},{"label":"HTML","tag":"h3","attrs":[{"attr":"","value":""}],"content":"South Central VA Health Care Network  VISN 16<br>\n&nbsp;","refreshOnChange":false,"key":"html","type":"htmlelement","input":false,"tableView":false},{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"Welcome to the Department of Veterans Affairs South Central VA Health Care Network donation page.   The VA South Central VA Health Care Network serves Alexandria, Biloxi, Fayetteville, Houston, Jackson, Little Rock, New Orleans, and Shreveport. Please click on the facility to which you would like to donate<br><br>\n\n<font color=\"red\">*</font> Required Field<br>&nbsp;","refreshOnChange":false,"key":"html2","type":"htmlelement","input":false,"tableView":false,"hideOnChildrenHidden":false},{"label":"Columns","columns":[{"components":[{"label":"Facility","widget":"html5","tableView":true,"dataSrc":"custom","data":{"custom":"list = [\r\n  {\r\n    \"label\": \"Veterans Health Care System of the Ozarks\",\r\n    \"locationCode\": \"564\",\r\n    \"name\": \"Veterans Health Care System of the Ozarks\",\r\n    \"title\": \"Veterans Health Care System of the Ozarks\",\r\n    \"image\": \"visn16_ozarks.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"Central Arkansas Veterans Healthcare System\",\r\n    \"locationCode\": \"598A0\",\r\n    \"name\": \"Central Arkansas Veterans Healthcare System\",\r\n    \"title\": \"Central Arkansas Veterans Healthcare System\",\r\n    \"image\": \"visn16_centralarkansas.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"Alexandria VA Health Care System\",\r\n    \"locationCode\": \"502\",\r\n    \"name\": \"Alexandria VA Health Care System\",\r\n    \"title\": \"Alexandria VA Health Care System\",\r\n    \"image\": \"visn16_alexandria.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"Southeast Louisiana Veterans Health Care System\",\r\n    \"locationCode\": \"629\",\r\n    \"name\": \"Southeast Louisiana Veterans Health Care System\",\r\n    \"title\": \"Southeast Louisiana Veterans Health Care System\",\r\n    \"image\": \"visn16_louisiana.jpg\",\r\n    \"maxWidth\" : \"350\"\r\n  },{\r\n    \"label\": \"Overton Brooks VA Medical Center, Shreveport, LA\",\r\n    \"locationCode\": \"667\",\r\n    \"name\": \"Overton Brooks VA Medical Center, Shreveport, LA\",\r\n    \"title\": \"Overton Brooks VA Medical Center, Shreveport, LA\",\r\n    \"image\": \"visn16_overtonbrooks.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"VA Gulf Coast Veterans Health Care System\",\r\n    \"locationCode\": \"520\",\r\n    \"name\": \"VA Gulf Coast Veterans Health Care System\",\r\n    \"title\": \"VA Gulf Coast Veterans Health Care System\",\r\n    \"image\": \"visn16_vagulfcoast.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"G.V. 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DeBakey VA Medical Center - Houston, TX\",\r\n    \"image\": \"visn16_michaeledebakey.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  }\r\n];\r\n\r\nvalues = _.sortBy(list, \"label\")"},"dataType":"string","valueProperty":"locationCode","validate":{"required":true},"key":"FacilityList","type":"select","input":true,"hideOnChildrenHidden":false}],"width":6,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":6},{"components":[{"label":"Facility","calculateValue":"switch (data.FacilityList) {\r\n\tcase \"564\" :\r\n  value = {\r\n    \"label\": \"Veterans Health Care System of the Ozarks\",\r\n    \"locationCode\": \"564\",\r\n    \"name\": \"Veterans Health Care System of the Ozarks\",\r\n    \"title\": \"Veterans Health Care System of the Ozarks\",\r\n    \"image\": \"visn16_ozarks.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"598A0\" :\r\n  value = {\r\n    \"label\": \"Central Arkansas Veterans Healthcare System\",\r\n    \"locationCode\": \"598A0\",\r\n    \"name\": \"Central Arkansas Veterans Healthcare System\",\r\n    \"title\": \"Central Arkansas Veterans Healthcare System\",\r\n    \"image\": \"visn16_centralarkansas.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"502\" :\r\n  value = {\r\n    \"label\": \"Alexandria VA Health Care System\",\r\n    \"locationCode\": \"502\",\r\n    \"name\": \"Alexandria VA Health Care System\",\r\n    \"title\": \"Alexandria VA Health Care System\",\r\n    \"image\": \"visn16_alexandria.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"629\" :\r\n  value = {\r\n    \"label\": \"Southeast Louisiana Veterans Health Care System\",\r\n    \"locationCode\": \"629\",\r\n    \"name\": \"Southeast Louisiana Veterans Health Care System\",\r\n    \"title\": \"Southeast Louisiana Veterans Health Care System\",\r\n    \"image\": \"visn16_louisiana.jpg\",\r\n    \"maxWidth\" : \"350\"\r\n  };\r\n  break;\r\n  case \"667\" :\r\n  value = {\r\n    \"label\": \"Overton Brooks VA Medical Center, Shreveport, LA\",\r\n    \"locationCode\": \"667\",\r\n    \"name\": \"Overton Brooks VA Medical Center, Shreveport, LA\",\r\n    \"title\": \"Overton Brooks VA Medical Center, Shreveport, LA\",\r\n    \"image\": \"visn16_overtonbrooks.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"520\" :\r\n  value = {\r\n    \"label\": \"VA Gulf Coast Veterans Health Care System\",\r\n    \"locationCode\": \"520\",\r\n    \"name\": \"VA Gulf Coast Veterans Health Care System\",\r\n    \"title\": \"VA Gulf Coast Veterans Health Care System\",\r\n    \"image\": \"visn16_vagulfcoast.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"586\" :\r\n  value = {\r\n    \"label\": \"G.V. (Sonny) Montgomery VA Medical Center\",\r\n    \"locationCode\": \"586\",\r\n    \"name\": \"G.V. (Sonny) Montgomery VA Medical Center\",\r\n    \"title\": \"G.V. (Sonny) Montgomery VA Medical Center\",\r\n    \"image\": \"visn16_gvsonnymontgomery.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"580\" :\r\n  value = {\r\n    \"label\": \"Michael E DeBakey, VA Medical Center - Houston, TX\",\r\n    \"locationCode\": \"580\",\r\n    \"name\": \"Michael E. DeBakey VA Medical Center - Houston, TX\",\r\n    \"title\": \"Michael E. DeBakey VA Medical Center - Houston, TX\",\r\n    \"image\": \"visn16_michaeledebakey.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n\t};\r\n\tbreak;\r\n\t\r\n\tdefault: \r\n\tvalue = \"\"; \r\n\tbreak;\r\n}","calculateServer":true,"key":"Facility","type":"hidden","input":true,"tableView":false,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[],"size":"md","width":2,"offset":0,"push":0,"pull":0,"currentWidth":2}],"key":"columns","type":"columns","input":false,"tableView":false},{"title":"Donation Information","collapsible":false,"key":"donationInformation","customConditional":"show = !_.isEmpty(data.Facility.locationCode);","type":"panel","label":"Donation Information","input":false,"tableView":false,"components":[{"label":"HTML","tag":"img","attrs":[{"attr":"src","value":"{{ config.STATIC_ASSETS_ENV }}/VAVISN/images/{{ data.Facility.image }}"},{"attr":"alt","value":"VISN Logo"},{"attr":"title","value":"VISN Logo"},{"attr":"style","value":"max-width: 250px;"}],"refreshOnChange":false,"key":"html1","logic":[{"name":"Hidden","trigger":{"type":"javascript","javascript":"result = (data.Facility.title === \"South East Louisiana - New Orleans, LA\");"},"actions":[{"name":"Hidden","type":"property","content":"<div class=\"well\">Content</div>","property":{"label":"Hidden","value":"hidden","type":"boolean"},"state":true}]}],"type":"htmlelement","input":false,"tableView":false,"refreshOn":"Facility"},{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"<br><strong>Welcome to the {{ data.Facility.title }} donation page.</strong><br><br>\r\nPlease use the drop-down menu to select the program in which you would like your donation to be used. If you do not have a specific use in mind, you may donate money for general use. Those funds are used to fund programs for veterans throughout the {{ data.Facility.title }}.<br><br>&nbsp;\r\n\r\n","refreshOnChange":true,"key":"html4","type":"htmlelement","input":false,"tableView":false},{"label":"Columns","columns":[{"components":[{"label":"Name","tableView":true,"validate":{"required":true,"custom":"valid = pgFormioGlobal().validateText(input);","maxLength":100},"key":"Name_Field","type":"textfield","input":true,"lockKey":true,"source":"5eac84259b53ff041c170ee7","isNew":true,"hideOnChildrenHidden":false},{"label":"Street Address","tableView":true,"validate":{"required":true,"custom":"valid = pgFormioGlobal().validateText(input);","maxLength":100},"key":"partyAddress1","type":"textfield","input":true,"hideOnChildrenHidden":false},{"label":"City","tableView":true,"validate":{"required":true,"custom":"valid = 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str.substr(0,5) + \"-\" + str.substr(5);\r\n    if (typeof instance != \"undefined\") {\r\n    \tinstance.setValue(str);\r\n    } else {\r\n    \tdata[component.key] = str;  \r\n    }\r\n    valid = true;\r\n  } else {\r\n    valid = \"Invalid Zip Code\";\r\n  }\r\n}","required":true},"key":"partyZipcode","type":"textfield","input":true,"hideOnChildrenHidden":false,"lockKey":true,"source":"5eac84259b53ff041c170ee7","isNew":true},{"label":"Phone Number","tableView":true,"validate":{"custom":"if (input === \"\" || input === null || input === undefined) {\r\n  valid = true;\r\n} else {\r\n  var regEx = /^\\(?\\d{3}\\)?\\s?-?\\d{3}-?\\d{4}$/;\r\n  if (!regEx.test(input)) {\r\n    valid = \"Invalid Telephone Number\";\r\n  } else {\r\n    var str = input.replace(/[^\\d]/g, \"\");\r\n    var newValue = \"(\"+ str.substr(0,3) + \") \" + str.substr(3,3) + \"-\" + str.substr(6);\r\n    if (typeof instance != \"undefined\") {\r\n     instance.setValue(newValue);\r\n    }\r\n    else {\r\n      data[component.key] = newValue;\r\n    }\r\n    valid = true;\r\n  }\r\n}"},"key":"partyPhone","type":"textfield","input":true,"hideOnChildrenHidden":false,"lockKey":true,"source":"5eac84259b53ff041c170ee7","isNew":true},{"label":"Program for Donation","widget":"html5","tableView":true,"dataSrc":"custom","data":{"custom":"var temp = [\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Emergent Veterans Needs\",\r\n        \"value\" : \"2004\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Veterans Creative Arts Local\",\r\n        \"value\" : \"2005\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"General Purpose Fund Non Specific Veterans Needs\",\r\n        \"value\" : \"2009\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Pharmacy Education \",\r\n        \"value\" : \"2010\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Veteran Center West Little Rock\",\r\n        \"value\" : \"2033\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Protestant Chaplain Service\",\r\n        \"value\" : \"2038\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Catholic Chaplain Service\",\r\n        \"value\" : \"2039\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Veteran Marriage Resiliency Program\",\r\n        \"value\" : \"2040\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Volunteer Advisory Committee\",\r\n        \"value\" : \"2056\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Homeless Veterans Programs\",\r\n        \"value\" : \"2057\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Disaster Readiness Program\",\r\n        \"value\" : \"2060\"\r\n    },\r\n    {\r\n     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      \"locationCode\" : \"598A0\",\r\n        \"label\" : \"National Salute to Veteran Patients\",\r\n        \"value\" : \"4026\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Veterans Outreach\",\r\n        \"value\" : \"4027\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Care Giver Support Program\",\r\n        \"value\" : \"4028\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Education Programs\",\r\n        \"value\" : \"4034\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Women Veterans Program\",\r\n        \"value\" : \"4035\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Veterans Memorial In Memory Of\",\r\n        \"value\" : \"4036\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Mental Health Outreach\",\r\n        \"value\" : \"4037\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Recreational Activities PTSD Unit\",\r\n        \"value\" : \"4038\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"598A0\",\r\n        \"label\" : \"Veterans Wood Turning Program\",\r\n        \"value\" : \"4039\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Homeless Veteran Programs\",\r\n        \"value\" : \"8231\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Women Veterans\",\r\n        \"value\" : \"8248\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Recreation Fund\",\r\n        \"value\" : \"8252\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Recreation Therapy\",\r\n        \"value\" : \"8254\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Social Work Indigent Patient Fund\",\r\n        \"value\" : \"8256\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Combat Veterans - Post Deployment\",\r\n        \"value\" : \"8258\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Lafayette Clinic\",\r\n        \"value\" : \"8260\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Lake Charles Clinic\",\r\n        \"value\" : \"8261\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Protestant Chaplain Fund\",\r\n        \"value\" : \"8262\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Catholic Chaplain Fund\",\r\n        \"value\" : \"8263\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"Vet Center\",\r\n        \"value\" : \"8264\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"502\",\r\n        \"label\" : \"National Salute\",\r\n        \"value\" : \"8265\"\r\n    },\r\n    {\r\n        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