{"_id":"676301251a027a31e4100108","title":"VA_VISN21_v3","name":"vaVisn21V3","path":"vavisn21v3","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/visn21_logo.jpg"},{"attr":"alt","value":"VA Capital Health Care Network VISN 21"},{"attr":"title","value":"VA Capital Health Care Network VISN 21"},{"attr":"style","value":"max-width: 500px;"}],"refreshOnChange":false,"key":"html1","type":"htmlelement","input":false,"tableView":false},{"label":"HTML","tag":"h3","attrs":[{"attr":"","value":""}],"content":"SIERRA PACIFIC NETWORK: VISN 21<br>\n&nbsp;","refreshOnChange":false,"key":"html","type":"htmlelement","input":false,"tableView":false},{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"Welcome to the Sierra Pacific Network donation page.  The Sierra Pacific Network serves Fresno, Honolulu, Nevada, Northern California, Palo Alto, Reno, and San Francisco. 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\": \"VA Central California Health Care System\",\r\n    \"locationCode\": \"570\",\r\n    \"name\": \"VA Central California Health Care System\",\r\n    \"title\": \"VA Central California Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the Central California VA Health Care system.\",\r\n    \"image\": \"visn21_fresno.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"Northern California Health Care System\",\r\n    \"locationCode\": \"612A4\",\r\n    \"name\": \"Northern California Health Care System\",\r\n    \"title\": \"Northern California Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the General Post Fund for the program you wish to support with your donation.  Your donation allows us to continue to provide for the needs of our Veterans in an enhanced patient-centered care environment. Thank you for helping us in Serving Those Who Served.\",\r\n    \"image\": \"visn21_northern_cali.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"Palo Alto VA Health Care System\",\r\n    \"locationCode\": \"640\",\r\n    \"name\": \"Palo Alto VA Health Care System\",\r\n    \"title\": \"Palo Alto VA Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used. The two accounts below are used to support all Veteran programs and activities in our health care system.  If you have any question, contact Voluntary Service at (650) 858-3903. Thank you for helping us in Serving Those Who Served\",\r\n    \"image\": \"visn21_palo_alto.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"VA Sierra Nevada Health Care System\",\r\n    \"locationCode\": \"654\",\r\n    \"name\": \"VA Sierra Nevada Health Care System\",\r\n    \"title\": \"VA Sierra Nevada Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the Sierra Nevada VA Health Care system.\",\r\n    \"image\": \"visn21_reno.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"San Francisco VA Health Care System\",\r\n    \"locationCode\": \"662\",\r\n    \"name\": \"San Francisco VA Health Care System\",\r\n    \"title\": \"San Francisco VA Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the San Francisco VA Health Care System.\",\r\n    \"image\": \"visn21_san_francisco.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"VA Pacific Islands Health Care System\",\r\n    \"locationCode\": \"459\",\r\n    \"name\": \"VA Pacific Islands Health Care System\",\r\n    \"title\": \"VA Pacific Islands Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the VA Pacific Islands Health Care System.  Thank you for helping us in Serving Those Who Served.\",\r\n    \"image\": \"visn21_pacific_islands.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  },{\r\n    \"label\": \"VA Southern Nevada Health Care System\",\r\n    \"locationCode\": \"593\",\r\n    \"name\": \"VA Southern Nevada Healthcare System\",\r\n    \"title\": \"VA Southern Nevada Healthcare System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the VA Southern Nevada Healthcare System.  Thank you for helping us in Serving Those Who Served.\",\r\n    \"image\": \"visn21_southern_nevada.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  }\r\n];\r\n\r\nvalues = _.sortBy(list, \"label\")\r\n"},"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 \"570\" :\r\n  value = {\r\n    \"label\": \"VA Central California Health Care System\",\r\n    \"locationCode\": \"570\",\r\n    \"name\": \"VA Central California Health Care System\",\r\n    \"title\": \"VA Central California Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the Central California VA Health Care system.\",\r\n    \"image\": \"visn21_fresno.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"612A4\" :\r\n  value = {\r\n    \"label\": \"Northern California Health Care System\",\r\n    \"locationCode\": \"612A4\",\r\n    \"name\": \"Northern California Health Care System\",\r\n    \"title\": \"Northern California Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the General Post Fund for the program you wish to support with your donation.  Your donation allows us to continue to provide for the needs of our Veterans in an enhanced patient-centered care environment. Thank you for helping us in Serving Those Who Served.\",\r\n    \"image\": \"visn21_northern_cali.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"640\" :\r\n  value = {\r\n    \"label\": \"Palo Alto VA Health Care System\",\r\n    \"locationCode\": \"640\",\r\n    \"name\": \"Palo Alto VA Health Care System\",\r\n    \"title\": \"Palo Alto VA Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used. The two accounts below are used to support all Veteran programs and activities in our health care system.  If you have any question, contact Voluntary Service at (650) 858-3903. Thank you for helping us in Serving Those Who Served\",\r\n    \"image\": \"visn21_palo_alto.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"654\" :\r\n  value = {\r\n    \"label\": \"VA Sierra Nevada Health Care System\",\r\n    \"locationCode\": \"654\",\r\n    \"name\": \"VA Sierra Nevada Health Care System\",\r\n    \"title\": \"VA Sierra Nevada Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the Sierra Nevada VA Health Care system.\",\r\n    \"image\": \"visn21_reno.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"662\" :\r\n  value = {\r\n    \"label\": \"San Francisco VA Health Care System\",\r\n    \"locationCode\": \"662\",\r\n    \"name\": \"San Francisco VA Health Care System\",\r\n    \"title\": \"San Francisco VA Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the San Francisco VA Health Care System.\",\r\n    \"image\": \"visn21_san_francisco.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"459\" :\r\n  value = {\r\n    \"label\": \"VA Pacific Islands Health Care System\",\r\n    \"locationCode\": \"459\",\r\n    \"name\": \"VA Pacific Islands Health Care System\",\r\n    \"title\": \"VA Pacific Islands Health Care System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the VA Pacific Islands Health Care System.  Thank you for helping us in Serving Those Who Served.\",\r\n    \"image\": \"visn21_pacific_islands.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n  };\r\n  break;\r\n  case \"593\" :\r\n  value = {\r\n    \"label\": \"VA Southern Nevada Health Care System\",\r\n    \"locationCode\": \"593\",\r\n    \"name\": \"VA Southern Nevada Healthcare System\",\r\n    \"title\": \"VA Southern Nevada Healthcare System\",\r\n    \"desc\": \"Please use the drop-down menu to select the program in which you would like your donation to be used.  Your donation will be used to help fund programs for Veterans throughout the VA Southern Nevada Healthcare System.  Thank you for helping us in Serving Those Who Served.\",\r\n    \"image\": \"visn21_southern_nevada.jpg\",\r\n    \"maxWidth\" : \"250\"\r\n };\r\n break;\r\n \r\n default: \r\n value = \"\"; \r\n break;\r\n}\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 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=== undefined || input === null) {\r\n  valid = true;\r\n} else {\r\n  var regEx = /^\\d{5}(-?\\d{4})?$/;\r\n  if (regEx.test(input)) {\r\n    var str = input.replace(/-/g, \"\");\r\n    str = str.length === 5 ? str : str.substr(0,5) + \"-\" + str.substr(5);\r\n    if (typeof instance != \"undefined\") {\r\n    \tinstance.setValue(str);\r\n    } else {\r\n    \tdata[component.key] = str;  \r\n    }\r\n    valid = true;\r\n  } else {\r\n    valid = \"Invalid Zip Code\";\r\n  }\r\n}","required":true},"key":"partyZipcode","type":"textfield","input":true,"hideOnChildrenHidden":false,"lockKey":true,"source":"5eac84259b53ff041c170ee7","isNew":true},{"label":"Phone Number","tableView":true,"validate":{"custom":"if (input === \"\" || input === null || input === undefined) {\r\n  valid = true;\r\n} else {\r\n  var regEx = /^\\(?\\d{3}\\)?\\s?-?\\d{3}-?\\d{4}$/;\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\" : \"570\",\r\n        \"label\" : \"Walk Of Honor\",\r\n        \"value\" : \"5475\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"570\",\r\n        \"label\" : \"General Purpose \",\r\n        \"value\" : \"5030\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"612A4\",\r\n        \"label\" : \"General Purpose\",\r\n        \"value\" : \"1400\"\r\n    },\r\n    {\r\n        \"locationCode\" : 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\"label\" : \"General Purpose (Palo Alto)\",\r\n        \"value\" : \"2202\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"640\",\r\n        \"label\" : \"General Purpose (Livermore)\",\r\n        \"value\" : \"3353\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"640\",\r\n        \"label\" : \"Returning Service Members and Family Members\",\r\n        \"value\" : \"2205\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"662\",\r\n        \"label\" : \"Hospital Non-Designated Funds\",\r\n        \"value\" : \"1015\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"662\",\r\n        \"label\" : \"Community Living Center\",\r\n        \"value\" : \"1036\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"662\",\r\n        \"label\" : \"General Recreation Fund\",\r\n        \"value\" : \"1007\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"662\",\r\n        \"label\" : \"Transportation Fund for Needy Veterans\",\r\n        \"value\" : \"1091\"\r\n    },\r\n    {\r\n    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\"locationCode\" : \"593\",\r\n        \"label\" : \"Emergency Fund for Indigent Veterans\",\r\n        \"value\" : \"1004\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"593\",\r\n        \"label\" : \"Refreshments for Infusion Patients\",\r\n        \"value\" : \"1014\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"593\",\r\n        \"label\" : \"Women Veterans\",\r\n        \"value\" : \"1017\"\r\n    },\r\n    {\r\n        \"locationCode\" : \"593\",\r\n        \"label\" : \"Fisher House\",\r\n        \"value\" : \"1030\"\r\n    }\r\n];\r\n\r\nvar values = [];\r\nfor (var i = 0; i < temp.length; i++) {\r\n  if (temp[i].locationCode === data.Facility.locationCode) {\r\n    values.push({\r\n      \"label\": temp[i].label,\r\n      \"value\": temp[i].value.toString()\r\n    });\r\n  }\r\n}"},"dataType":"string","valueProperty":"value","refreshOn":"FacilityList","clearOnRefresh":true,"calculateServer":true,"validate":{"required":true},"key":"programForDonation","type":"select","input":true,"hideOnChildrenHidden":false},{"label":"Donation Amount","description":"(the minimum donation is $5.00)","mask":false,"spellcheck":true,"tableView":false,"currency":"USD","inputFormat":"plain","validate":{"required":true,"custom":"if (_.isNil(input)) {\r\n  valid = true;\r\n} else {\r\n  if (input < parseFloat(data.minMax.minAmount)) {\r\n\t    valid = \"Your payment is below the allowed amount. Please enter a higher dollar amount.\";\r\n\t  } else if (input > parseFloat(data.minMax.maxAmount)) {\r\n\t    valid = \"Your payment is above the maximum allowed amount. 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In accordance with Title 38 U.S.C. 8301, the Secretary of Veterans Affairs may accept gifts, for use in carrying out all laws administered by VA, which enhance the Secretary's ability to provide services and benefits to the veteran.  No goods or services are provided by the Department of Veterans Affairs in return for your contribution.  A donation to support any of the Department's programs is tax deductible, whether the donor directs that the donated funds be used for a specific purpose, or allows the Department to decide how the donated funds will be used.<br>&nbsp;","refreshOnChange":false,"key":"html3","type":"htmlelement","input":false,"tableView":false}]},{"label":"Standard Buttons","columns":[{"components":[{"label":"Continue","showValidations":false,"block":true,"customClass":"usa-button","tableView":false,"key":"submit","customConditional":"show = !data.showReassignButton ? true : data.showSubmitButton;","type":"button","input":true,"hideOnChildrenHidden":false}],"width":2,"offset":0,"push":0,"pull":0,"size":"md","currentWidth":2},{"components":[{"label":"View PDF","action":"event","showValidations":false,"block":true,"customClass":"usa-button 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