{% extends "layouts/source_user_base.html" %} {% load i18n %} {% block title %}{% trans "Create Complaint" %} - {{ source.name_en }}{% endblock %} {% block extra_css %} {% endblock %} {% block content %}

{% trans "Create Complaint" %}

{% trans "Submit a new complaint from" %} {{ source.name_en }}

{% trans "Back to Complaints" %}

{% trans "Source Information" %}

{% trans "This complaint will be automatically linked to" %} {{ source.name_en }}. {% trans "All required fields are marked with" %} *

{% csrf_token %}
{{ form.complainant_name }} {% if form.complainant_name.errors %}
{% for error in form.complainant_name.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.mobile_number }} {% if form.mobile_number.errors %}
{% for error in form.mobile_number.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.email }} {% if form.email.errors %}
{% for error in form.email.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.relation_to_patient }} {% if form.relation_to_patient.errors %}
{% for error in form.relation_to_patient.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.patient_name }} {% if form.patient_name.errors %}
{% for error in form.patient_name.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.national_id }} {% if form.national_id.errors %}
{% for error in form.national_id.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.incident_date }} {% if form.incident_date.errors %}
{% for error in form.incident_date.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.staff_name }}

{% trans "Optional - Name of staff involved" %}

{% if form.staff_name.errors %}
{% for error in form.staff_name.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.hospital }} {% if form.hospital.errors %}
{% for error in form.hospital.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.location }} {% if form.location.errors %}
{% for error in form.location.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.main_section }} {% if form.main_section.errors %}
{% for error in form.main_section.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.subsection }} {% if form.subsection.errors %}
{% for error in form.subsection.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.complaint_details }} {% if form.complaint_details.errors %}
{% for error in form.complaint_details.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.expected_result }}

{% trans "What do you expect as a resolution? (Optional)" %}

{% if form.expected_result.errors %}
{% for error in form.expected_result.errors %}{{ error }}{% endfor %}
{% endif %}
{% trans "Cancel" %}
{% endblock %}