@include('admin.layouts.components.form_modal_validasi')
@php
    $sekarang = $log_status_dasar['tgl_peristiwa'] != '' ? $log_status_dasar['tgl_peristiwa'] : date('d-m-Y');
@endphp
<form action="{{ $form_action }}" method="post" id="validasi" class="tgl_lapor_peristiwa" enctype="multipart/form-data">
    <div class='modal-body'>
        <div class="form-group">
            <label for="status_dasar">Status Dasar Baru</label>
            <select id="status_dasar" name="status_dasar" class="form-control select2 input-sm required">
                <option value="">Pilih Status Dasar</option>
                @foreach ($list_status_dasar as $key => $value)
                    <option value="{{ $key }}" @selected($key == $nik['status_dasar_id'])>
                        {{ $value }}</option>
                @endforeach
            </select>
        </div>
        <div class="form-group mati">
            <label for="meninggal_di">Tempat Meninggal</label>
            <input name="meninggal_di" class="form-control input-sm" type="text" maxlength="50" placeholder="Tempat Meninggal"></input>
        </div>
        <div class="form-group mati">
            <label for="jam_mati">Jam Kematian</label>
            <div class="input-group input-group-sm ">
                <div class="input-group-addon">
                    <i class="fa fa-clock-o"></i>
                </div>
                <input name="jam_mati" id="jammenit_1" class="form-control input-sm" type="text" maxlength="50" placeholder="Jam Kematian"></input>
            </div>
        </div>
        <div class="form-group mati">
            <label for="sebab">Penyebab Kematian</label>
            <select id="sebab" name="sebab" class="form-control select2 input-sm required">
                <option value="">Pilih Penyebab Kematian</option>
                @foreach ($sebab as $key => $value)
                    <option value="{{ $key }}">{{ $value }}</option>
                @endforeach
            </select>
        </div>
        <div class="form-group mati">
            <label for="penolong_mati">Yang Menerangkan Kematian</label>
            <select id="penolong_mati" name="penolong_mati" class="form-control select2 input-sm required">
                <option value="">Pilih Yang Menerangkan Kematian</option>
                @foreach ($penolong_mati as $key => $value)
                    <option value="{{ $key }}">{{ $value }}</option>
                @endforeach
            </select>
        </div>
        <div class="form-group mati">
            <label for="anak_ke">Anak Ke-</label>
            <input name="anak_ke" class="form-control input-sm" type="number" min="1" placeholder="Anak Ke" value="{{ $nik['kelahiran_anak_ke'] }}"></input>
        </div>
        <div class="form-group mati">
            <label for="akta_mati">Nomor Akta Kematian</label>
            <input name="akta_mati" class="form-control input-sm" type="text" maxlength="50" placeholder="Nomor Akta Kematian"></input>
        </div>
        <div class="form-group mati">
            <label for="file">File Akta Kematian : <code>(.jpg, .jpeg, .png, .pdf)</code></label>
            <div class="input-group input-group-sm">
                <input type="text" class="form-control" id="file_path" name="satuan">
                <input type="file" class="hidden" id="file" name="nama_file" accept=".jpg,.jpeg,.png,.pdf">
                <span class="input-group-btn">
                    <button type="button" class="btn btn-info" id="file_browser"><i class="fa fa-search"></i> Cari</button>
                </span>
            </div>
            <span class="help-block"><code>Kosongkan jika tidak ingin mengubah dokumen. Ukuran maksimal
                    <strong>{{ max_upload() }} MB</strong>.</code></span>
        </div>
        <div class="form-group pindah">
            <div class="form-group">
                <label for="ref_pindah">Tujuan Pindah</label>
                <select name="ref_pindah" class="form-control select2 input-sm required">
                    <option value="">Pilih Tujuan Pindah</option>
                    @foreach ($list_ref_pindah as $key => $value)
                        <option value="{{ $key }}" @selected($key == $nik['ref_pindah'])>{{ $value }}
                        </option>
                    @endforeach
                </select>
            </div>
            <div class="form-group">
                <label for="alamat_tujuan">Alamat Tujuan</label>
                <textarea id="alamat_tujuan" name="alamat_tujuan" class="form-control input-sm" placeholder="Alamat Tujuan" style="height: 50px;"></textarea>
            </div>
        </div>
        <div class="form-group">
            <label for="tgl_peristiwa">Tanggal Peristiwa</label>
            <div class="input-group input-group-sm date">
                <div class="input-group-addon">
                    <i class="fa fa-calendar"></i>
                </div>
                <input class="form-control input-sm pull-right required tgl_minimal" id="tgl_1" name="tgl_peristiwa" type="text" data-tgl-lebih-besar="#tgl_lapor" value="{{ $sekarang }}">
            </div>
        </div>
        <div class="form-group">
            <label for="tgl_lapor">Tanggal Lapor</label>
            <div class="input-group input-group-sm date">
                <div class="input-group-addon">
                    <i class="fa fa-calendar"></i>
                </div>
                <input class="form-control input-sm pull-right tgl_indo required" id="tgl_lapor" name="tgl_lapor" type="text" value="{{ $sekarang }}">
            </div>
        </div>
        <div class="form-group">
            <label for="catatan">Catatan Peristiwa</label>
            <textarea id="catatan" name="catatan" class="form-control input-sm" placeholder="Catatan" rows="5"></textarea>
        </div>
        <div class="alert alert-warning alert-dismissible" style="margin-bottom: -5px;">
            <h4><i class="icon fa fa-warning"></i> Catatan!</h4>
            <ul style="margin-left: -25px;">
                <li>Jika kepala keluarga meninggal, harap melakukan pemecahan Kartu Keluarga (KK) terlebih dahulu.</li>
                <li>Jika terdapat keterangan lain terkait perubahan status dasar, harap diisi pada kolom catatan peristiwa.</li>
            </ul>
        </div>
    </div>
    <div class="modal-footer">