Trouble Inserting data from form

ptrane55 · August 24, 2009

I am a newbie having trouble inserting data into a Sql Server 2005 database. I am able to write data if i manually add the values, but not having any luck when inputting data from the form. Here is the code.

test.php

<?php

//connect to a DSN "myDSN"

$conn = odbc_connect('','','');

if ( $conn === false )

{

echo "Could not connect.\n";

die( print_r( sqlsrv_errors(), true));

}

else {

echo "Connection Successful <br />";

}

//the SQL statement that will query the database

/*$query = "INSERT INTO near_miss_incident (INCIDENT_ID,

date_of_incident,

incident_loc_id,

safety_eq_utilized_yn,

onsite_treatment_yn,

location_incident_occured,

incident_desc)

VALUES

(1014,08/21/2009,'hallway','y','y','waiting room','felldown')";*/ This works

$incident_id = $_REQUEST['incident_id'];

$date_of_incident = $_REQUEST[date_of_incident];

$incident_loc_id = $_REQUEST['incident_loc_id'];

$safety_eq_utilized_yn = $_REQUEST['safety_eq_utilized_yn'];

$onsite_treatment_yn = $_REQUEST['onsite_treatment_yn'];

$location_incident_occured = $_REQUEST['location_incident_occured'];

$incident_desc = $_REQUEST['incident_desc'];

//$failed_procedure = $_REQUEST['failed_procedure'];

//the SQL statement that will query the database

$query = "INSERT INTO near_miss_incident (INCIDENT_ID,

date_of_incident,

incident_loc_id,

safety_eq_utilized_yn,

onsite_treatment_yn,

location_incident_occured,

incident_desc)

VALUES

('$incident_id',

$date_of_incident,

'$incident_loc_id',

'$safety_eq_utilized_yn',

'$onsite_treatment_yn',

'$location_incident_occured',

'$incident_desc')";

//$failed_procedure

//perform the query

$result=odbc_exec($conn, $query);

if( $result === false )

{

echo "Error in statement execution.\n <br />";

die( print_r( sqlsrv_errors(), true));

}

else

{

echo "<b><center>Near Miss Report Submitted, Thank You!<center></b>";

echo "<a href='http://www.esseintranet.com/accidentreportformnew.php'></a>";

}

?>

Here is the web form.

<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">

<link href="accreportA.css" rel="stylesheet" type="text/css"

function showHide(shID) {

if (document.getElementById(shID)) {

if (document.getElementById(shID+'-show').style.display != 'none') {

document.getElementById(shID+'-show').style.display = 'none';

document.getElementById(shID).style.display = 'block';

}

else {

document.getElementById(shID+'-show').style.display = 'inline';

document.getElementById(shID).style.display = 'none';

}

function MM_validateForm() { //v4.0

if (document.getElementById){

var i,p,q,nm,test,num,min,max,errors='',args=MM_validateForm.arguments;

for (i=0; i<(args.length-2); i+=3) { test=args[i+2]; val=document.getElementById(args);

if (val) { nm=val.name; if ((val=val.value)!="") {

if (test.indexOf('isEmail')!=-1) { p=val.indexOf('@');

if (p<1 || p==(val.length-1)) errors+='- '+nm+' must contain an e-mail address.\n';

} else if (test!='R') { num = parseFloat(val);

if (isNaN(val)) errors+='- '+nm+' must contain a number.\n';

if (test.indexOf('inRange') != -1) { p=test.indexOf(':');

min=test.substring(8,p); max=test.substring(p+1);

if (num<min || max<num) errors+='- '+nm+' must contain a number between '+min+' and '+max+'.\n';

} } } else if (test.charAt(0) == 'R') errors += '- '+nm+' is required.\n'; }

} if (errors) alert('The following error(s) occurred:\n'+errors);

document.MM_returnValue = (errors == '');

} }

</script>

<script type="text/JavaScript">

/******* Menu 0 Add-On Settings *******/

var a = qmad.qm0 = new Object();

// Rounded Corners Add On

a.rcorner_size = 6;

a.rcorner_border_color = "#dadada";

a.rcorner_bg_color = "#F7F7F7";

a.rcorner_apply_corners = new Array(false,true,true,true);

a.rcorner_top_line_auto_inset = true;

// Rounded Items Add On

a.ritem_size = 4;

a.ritem_apply = "main";

a.ritem_main_apply_corners = new Array(true,true,false,false);

a.ritem_show_on_actives = true;

// IE Over Select Fix Add On

a.overselects_active = true;

/******* Menu 2 Add-On Settings *******/

var a = qmad.qm2 = new Object();

// Rounded Corners Add On

a.rcorner_size = 6;

a.rcorner_border_color = "#dadada";

a.rcorner_bg_color = "#F7F7F7";

a.rcorner_apply_corners = new Array(false,true,true,true);

a.rcorner_top_line_auto_inset = true;

// Rounded Items Add On

a.ritem_size = 4;

a.ritem_apply = "main";

a.ritem_main_apply_corners = new Array(true,true,false,false);

a.ritem_show_on_actives = true;

// IE Over Select Fix Add On

a.overselects_active = true;

</script>

<title>Accident Report Form</title>

</head>

<body>

<div id="container">

<div id="intro">

<h2 id="head">Accident/Incident/Near Miss Report</h2>

<p>Please comploete the infiomation below and click on the 'Submit Form' button. Your report will automatically be forwarded to the appropriate personnel.<br />

<div id="require">

*Indicates a required field

</div>

<div id="content">

<form action="test.php" method="POST">

<div id="preamble">

<div id="dates">

<p>

Today's Date: <input type="text" name="incident_id" value="<?=date("m.d.Y");?>" id="todaysdate" size="10" >

</p>

<p class="date">*Date of Incident:

<input name="date_of_incident" type="text" id="date_of_incident" value="" size="12" maxlength="12" />

</p>

<div id="times">

<p>Time of Incident:

<input name="timeincident" type="text" id="timeincident" value="<?=(strftime("%H:%M:%S",time()));?>" size="19" maxlength="19" />

</p>

</div>

<div id="location">

<p class="date">*Location of Incident<br />

<select name="incident_loc_id" size="1" id="incident_loc_id" >

<option value="choose" selected>Choose One</option>

<option value="waitingroom">Waiting Room</option>

<option value="examroom">Exam Room</option>

<option value="hallway">Hallway</option>

<option value="stairs">Stairs</option>

<option value="parkinglot">Parking Lot</option>

<option value="lab">Lab</option>

<option value="xray">X-Ray</option>

<option value="other">Other</option>

</select>

</p>

<p>If Oher, Please List:

<br />

<input name="otherlocation" type="text" id="otherlocation" size="42" maxlength="60" />

<p>Patient:<br />

<select name="patient" id="patient">

<option value="choose" selected>Choose One</option>

<option>Patient</option>

<option>Visitor</option>

<option>Employee</option>

</select>

<p>Job Classification

<select name="job" size="1" id="job" >

<option value="choose" selected>Choose One</option>

<option value="psr">PSR</option>

<option value="ma">MA</option>

<option value="referrals">Referrals</option>

<option value="lab">Lab</option>

<option value="xray">X-Ray</option>

<option value="om">OM</option>

<option value="admin">Admin</option>

<option value="nurse">Nurse</option>

<option value="physician">Physician</option>

</select>

</p>

</div>

<div id="indiv">

<p class="date">*Name of Individual / Individuals Involved<br />

*First Name:<br /><input name="firstname" type="text" id="firstname" size="12" /></p>

<p class="date">*Initial:<br /><input name="middleinit" type="text" id="middleinit" size="2" /></p>

<p class="date">*Last Name:<br /><input name="lastname" type="text" id="lastname" size="18" /></p>

</p>

<p class="date">* Home Address:<br />

<textarea name="address" cols="25%" rows="5" id="address" ></textarea>

</p>

<p class="date">* Telephone #: <br />

<input name="phone" type="text" id="phone" size="10" maxlength="12" />

xxx-xxx-xxxx</p>

</div>

<div id="genddob">

<p class="date">* Date of Birth<br />

<input name="dob" type="text" id="dob" size="10" maxlength="10" />

mm/dd/yyyy

</p>

<p class="date">* Gender<br />

<input name="gender" type="text" id="gender" size="6" maxlength="8" />

</p>

<p>MRN <br />

<input name="mrn" type="text" id="mrn" size="6" maxlength="8" />

</p>

</div>

<div id="incident">

<p id="descincident" class="date"> </p>

<p class="date"> </p>

<p class="date">* Description of Incident: (<strong>be Specific</strong>)<br />

<textarea name="incident_desc" cols="25%" rows="5" wrap="virtual" id="incident_desc"></textarea>

<br />

</p>

<p class="date">* Exact Location of Incident<br />

<input name="location_incident_occured" type="text" id="location_incident_occured" size="70" maxlength="80" />

<br />

</p>

<p class="date">* Witness and Relationship to Involved Individual<br />

<textarea name="witness" cols="35%" rows="2" wrap="virtual" id="witness"></textarea>

</p>

<p class="date">* Did accident or injury require medical treatment?<br>

<select name="treatment" id="treatment">

<option value="choose" selected">Choose</option>

<option value="Yes">Yes</option>

<option value="No">No</option>

</select>

</p>

<p>If no, choose one:: <br />

<select name="choose" size="1" id="choose">

<option value="choose" selected">Choose One</option>

<option value=notreatmentrequired">No Treatment Required</option>

<option value="refused">Refused</option>

<option value="other">Other</option>

</select>

<br />

</p>

<p>If Medical Treatment was Required, Please complete the Following:</p>

<p>Was medical treatment provided on site?

<select name="onsite_treatment_yn" id="onsite_treatment_yn">

<option value="choose" selected>Choose One</option>

<option value="yes">Yes</option>

<option value="no">No</option>

</select>

</p>

<p>If no, where was treatment provided?

<textarea name="providedby" cols="35%" rows="2" wrap="virtual" id="providedby"></textarea>

</p>

<p>Treating Physician:<br />

<input name="trphysician" type="text" id="trphysician" size="20" maxlength="30" />

</p>

<p>Diagnosis:<br />

<input name="diagnosis" type="text" id="diagnosis" size="20" maxlength="30" />

</p>

<p>Treatment:<br />

<textarea name="treatment" cols="45%" rows="2" wrap="virtual" id="treatment"></textarea>

</p>

<p>Disposition:<br />

<textarea name="deposition" cols="45%" rows="2" wrap="virtual" id="deposition"></textarea>

</p>

<p>Has patient or third party contacted Esse since incident occurred?<br />

<select name="thirdparty" id="thirdparty">

<option value="choose" selected>Choose One</option>

<option value="yes">Yes</option>

<option value="no">No</option>

</select>

</p>

<p>Explain:<br />

<textarea name="thirdpartyexplain" cols="45%" rows="5" wrap="virtual" id="thirdpartyexplain"></textarea>

</p>

</div>

<p class="date">Please Choose Appropriate Categories and Complete Questions</p>

<p><a href="#" id="ocexpose-show" class="showLink" onClick="showHide('ocexpose');return false;">Occupation Exposure</a></p>

<div id="ocexpose" class="more">

<p><a href="#" type="#" id="ocexpose-hide" class="showLink" onClick="showHide('ocexpose');return false;">Hide Occupation Exposure</a></p>

<h3>Occupation Exposure Section</h3>

<h4> Nature of Incident</h4>

<select name="incidentnature" size="4" multiple id="incidentnature">

<option value="choose" selected>Choose One / Mulitple</option>

<option value="needlestick"> Needlestick / sharps accident</option>

<option value="membrane">Contact with mucous membrane (eyes, mouth, nose)</option>

<option value="skin">Contact with non-intact skin</option>

</select><br /><br />

<input type="checkbox" name="contactother" value="checkbox" id="contactother" />

Other

<input name="otherexposure" type="text" id="otherexposure" size="35" maxlength="40" />

<br />

<h4>Fluids Exposed to:</h4>

<select name="infectiousfluid" size="4" mulitple id="infectiousfluid" />

<option value="choose" selected>Choose One / Multiple</option>

<option value="Blood">Blood</option>

<option value="VaginalSecretions">Vaginal Secretions</option>

<option value="Semen">Semen</option>

<option value="UrineBlood">Urine with Blood Present</option>

<option value="SynovialFluid">Synovial Fluid</option>

<option value="PleuralFluid">Pleural Fluid</option>

<option value="PeritonealFluid">Peritoneal Fluid</option>

<option value="CerebralSpinalFluid">Cerebral Spinal Fluid</option>

</select>

<p>Source:</p>

<select name="knownfluid" size="1" id="knownfluid" />

<option value="choose" selected>Choose One</option>

<option value="known">Known</option>

<option value="unknown">Unknown</option>

</select>

<p>List Source:</p>

<input name="sourcefluid" type="text" id="sourcefluid" size="35" maxlength="40" />

<br />

<input type="checkbox" name="chemicalchkbox" value="checkbox" id="chemicalchkbox" />

Chemical or Drug - List<br />

<textarea name="druglist" cols="55" rows="2" wrap="virtual" id="druglist"></textarea>

<br />

<input type="checkbox" name="otherfluidchkbox" value="checkbox" id="otherfluidchkbox" />

Other

<input name="otherfluidtext" type="text" id="otherfluidtext" size="40" maxlength="40" />

<br />

<h4>Personal Protective Equipment (PPE) being worn at time of exposure<br />

Check all that apply:</h4>

<select name="safety_eq_utilized_yn" size="5" multiple id="safety_eq_utilized_yn">

<option value="choose" selected>Choose One / Multiple</option>

<option value="gloves"> Gloves</option>

<option value="labcoat"> Lab coat / gown</option>

<option value="mask">Mask / face shield</option>

<option value="none">None</option>

</select>

<h4>Safety Device and Brand Used:</h4>

List

<input name="safetydevicelist" type="text" id="safetydevicelist" size="60" maxlength="70" /><br />

<br />

None

- List Reason as to Why a Safety Device was not Utilized<br />

<textarea name="reasonnosafetydevice" cols="55" rows="2" wrap="virtual" id="reasonnosafetydevice"></textarea>

<br />

Part of Body Exposed <br />

<input name="bodyexposed" type="text" id="bodyexposed" size="30" maxlength="40" />

<br />

How long was the exposure? <br />

<input name="howlongexposed" type="text" id="howlongexposed" size="30" maxlength="40" />

</p>

<p>Was the area <br />

<select name="wasareawashed" size="2" multiple id="wasareawashed">

<option value="choose" selected>Choose One / Multiple</option>

<option value="washed"> Washed</option>

<option value="flushed"> Flushed</option>

</select>

<p>If no, reason: <br />

<textarea name="ifnotwashed" cols="55" rows="2" wrap="virtual" id="ifnotwashed"></textarea>

</p>

<p>Fluid Injected into the Body?<br />

<select name="fluidinjected" id="fluidinjected">

<option value="choose" selected>Choose One</option>

<option value="yes">Yes</option>

<option value="no">No</option>

</select>

<p>If yes, amount

<input type="text" name="amountinjected" id="amountinjected" />

</p>

<p>Did the injury bleed freely?<br />

<select name="injurybleed" id="injurybleed">

<option value="choose" selected>Choose One</option>

<option value="yes">Yes</option>

<option value="no">No</option>

</select>

<p>Has the exposed employee received the Hepatitis B vaccine?<br />

<select name="hepshot" id="hepshot">

<option value="choose" selected>Choose One</option>

<option value="yes">Yes</option>

<option value="no">No</option>

</select>

<p>Has the exposed employee received the Tetanus booster?<br />

<select name="tetnasshot" id="tetnasshot">

<option value="choose" selected>Choose One</option>

<option value="yes">Yes</option>

<option value="no">No</option>

</select>

</div>

<p><a href="#" id="accident-show" class="showLink" onClick="showHide('accident');return false;">Accident / Injury</a></p>

<div id="accident" class="more">

<p><a href="#" id="accident-hide" class="showLink" onClick="showHide('accident');return false;">Hide Accident / Injury</a></p>

<h3>Accident / Injury</h3>

<select name="injurytype" size="8" multiple id="injurytype">

<option value="choose" selected>Choose One / Multiple</option>

<option value="burn">Burn</option>

<option value="shock">Electrical Shock</option>

<option value="fall">Slip / Fall</option>

<option value="hearingloss">Hearing Loss</option>

<option value="unconscious">Loss of Conscious</option>

<option value="puncture">Puncture</option>

<option value="respiratoryinhalation">Respiratory Inhalation</option>

<option value="skinirritant">Skin Irritant</option>

<option value="death">Death</option>

<option value="other">Other</option>

</select>

<p>Explain:<br />

<textarea name="explainaccident" cols="55" rows="3" wrap="virtual" id="explainaccident"></textarea>

</p>

</div>

<p><a href="#" id="patients-show" class="showLink" onClick="showHide('patients');return false;">Patient-Physician Relationship / Hospitalization</a></p>

<div id="patients" class="more">

<p><a href="#" id="patients-hide" class="showLink" onClick="showHide('patients');return false;">Hide Patient-Physician Relationship / Hospitalization</a></p>

<h3>Patient-Physician Relationship / Hospitalization</h3>

<select name="patphysrelationship" size="4" multiple id="patphysrelationship">

<option value="choose" selected>Choose One / Multiple</option>

<option value="admissionorer">Unexpected hospitalization within 24 hours of physician office visit (admission or ER)</option>

<option value="disagreemetphysician">Disagreement between physician and patient as to treatment</option>

<option value="patientcomplaint">Patient complaint of dissatisfaction with physician</option>

<option value="other">Other</option>

</select>

<br />

<p>Explain:<br />

<textarea name="explaincomplaint" cols="55" rows="3" wrap="virtual" id="explaincomplaint"></textarea>

</p>

</div>

<p><a href="#" id="ppe-show" class="showLink" onClick="showHide('ppe');return false;">Labs / X-Ray / Procedure</a></p>

<div id="ppe" class="more">

<p><a href="#" id="ppe-hide" class="showLink" onClick="showHide('ppe');return false;">Hide Labs / X-Ray / Procedure</a></p>

<h3>Labs / X-Ray / Procedure</h3>

<select name="procedure" size="8" multiple id="procedure">

<option value="choose">Choose One / Multiple</option>

<option value="labsnotordered">Labs/x-rays/procedures not ordered</option>

<option value="labsordered">Labs/x-rays/procedures ordered but not drawn or performed</option>

<option value="labsnoresults">Labs/x-rays/procedure drawn or ordered but results not obtainedn</option>

<option value="failuretonotify">Failure to notify patient of lab/x-ray/procedure results</option>

<option value="misrepresentationofresults">Misrepresentation of results to patient (staff or physician)</option>

<option value="failutetoact">Failure to act on abnormal results (when action is appropriate)</option>

<option value="faiutetostarttreatment">Failure to start treatment due to a delay in test results</option>

<option value="misdiagnosis">Misdiagnosis</option>

<option value="other">Other</option>

</select>

<p>Explain:<br />

<textarea name="explainlab" cols="55" rows="3" wrap="virtual" id="explainlab"></textarea>

</p>

</div>

<p><a href="#" id="med-show" class="showLink" onClick="showHide('med');return false;">Medication Errors</a></p>

<div id="med" class="more">

<p><a href="#" id="accident-hide" class="showLink" onClick="showHide('med');return false;">Hide Medication Errors</a></p>

<h3>Medication Errors</h3>

<select name="mederrors" size="4" multiple id="mederrors">

<option value="choose" selected>Choose One / Multiple</option>

<option value="wrongpatient">Injection given to the wrong patient</option>

<option value="wronginjection">Patient received the wrong injection (prescribed)</option>

<option value="wrongmeds">Wrong medication prescribed</option>

<option value="druginteraction">Drug interaction</option>

<option value="impropertherapy">Improper choice of therapy</option>

<option value="other">Other</option>

</select>

<p>Explain:<br />

<textarea name="explainmeds" cols="55" rows="3" wrap="virtual" id="explainmeds"></textarea>

</p>

</div>

<p><a href="#" id="equip-show" class="showLink" onClick="showHide('equip');return false;">Equipment Failure</a></p>

<div id="equip" class="more">

<p><a href="#" id="equip-hide" class="showLink" onClick="showHide('equip');return false;">Hide Equipment Failure</a></p>

<h3>Equipment Failure</h3>

<select name="equipfail" size="4" multiple id="equipfail">

<option value="choose" selected>Choose One / Multiple</option>

<option value="wronginfusion">Wrong infusion amount</option>

<option value="equipmentfailed">Equipment function failure</option>

<option value="wrongequipment">Wrong equipment use</option>

<option value="lackofsupplies">Lack of equipment or supplies</option>

<option value="procedurenotfollowed">Proper procedure not followed</option>

<option value="other">Other</option>

</select>

<p>Explain:<br />

<textarea name="explainequip" cols="55" rows="3" wrap="virtual" id="explainequip"></textarea>

</p>

</div>

<p><a href="#" id="misc-show" class="showLink" onClick="showHide('equip');return false;">Miscellaneous</a></p>

<div id="misc" class="more">

<p><a href="#" id="misc-hide" class="showLink" onClick="showHide('equip');return false;">Hide Miscellaneous</a></p>

<h3>Miscellaneous / Other</h3>

<p>Explain:<br />

<textarea name="explainmisc" cols="55" rows="3" wrap="virtual" id="explainmisc"></textarea>

</p>

</div>

<div id="reporter">

<p class="date">*Name of Employee Preparing Report:<br />

<input name="employeename" type="text" id="employeename" size="35" maxlength="40" />

<p class="date">*Location:<br />

<select name="employee location" size="1" id="locations">

<option value="choose" selected>Choose One</option>

<option value="Administration">Administration</option>

<option value="Coding">Coding</option>

<option value="Compliance">Compliance</option>

<option value="Credentialing">Credentialing</option>

<option value="Finance">Finance</option>

<option value="HR">Human Resources</option>

<option value="InsuranceorPtAccounts">Insurance/Pt Accounts</option>

<option value="Laboratory">Laboratory</option>

<option value="MIS">MIS</option>

<option value="Purchasing">Purchasing</option>

<option value="BellevilleInternalMedicine">Belleville Internal Medicine</option>

<option value="BrentwoodEsseHealth">Brentwood Esse Health</option>

<option value="ByrneandLaunchNorth">Byrne and Launch North</option>

<option value="ByrneandLaunchStPeters">Byrne and Launch St Peters</option>

<option value="CreveCoeurPeds">Creve Coeur Pediatrics</option>

<option value="ExcelImaging">Excel Imaging</option>

<option value="FestusInternalMedicine">Festus Internal Medicine</option>

<option value="FlorissantInternalMedicine">Florissant Internal Medicine</option>

<option value="FlorissantPeds">Florissant Pediatrics</option>

<option value="GatewayAandAEast">Gateway Asthma and Allergy (East)</option>

<option value="GatewayAandASouth">Gateway Asthma and Allergy (South)</option>

<option value="HastingsOffices">Esse West</option>

<option value="KennerlyInternalMedicine">Kennerly Internal Medicine</option>

<option value="KirkwoodEsseInternalMedicine">Kirkwood Esse Internal Medicine</option>

<option value="KnappOffices">Knapp Offices</option>

<option value="McLaughlinOffices">McLaughlin Offices</option>

<option value="NorthCountyInternalMedicine">North County Internal Medicine</option>

<option value="OFallonPeds">OFallon Pediatrics</option>

<option value="PliscoOfficesNorth">North County Plisco Offices</option>

<option value="PliscoOfficesStCharles">St Charles Plisco Offices</option>

<option value="RichmondHeightsInternalMedicine">Richmond Heights Internal Medicine</option>

<option value="SouthCountyInternalMedicine">South County Internal Medicine</option>

<option value="SouthroadsInternalMedicine">Southroads Internal Medicine</option>

<option value="SouthsideFamilyPractice">Southside Family Practice</option>

<option value="StCharlesInternalMedicine">St Charles Internal Medicine</option>

<option value="SwanseaInternalMedicine">Swansea Internal Medicine</option>

<option value="TessonPediatrics">Tesson Pediatrics</option>

<option value="TessonInternalMedicine">Tesson Internal Medicine</option>

<option value="WatsonPeds">Watson Pediatrics</option>

<option value="WepprichOffices">Wepprich Offices</option>

<option value="WiednerOffices">Wiedner Offices</option>

</select>

</p>

<p class="date">*Other employees with knowledge of incident::<br />

<textarea name="otherempknowledge" cols="25%" rows="3" wrap="virtual" id="otherempknowledge"></textarea>

</p>

<p> </p>

</div>

<div id="subbutton">

<input type="reset" value="RESET" name="reset" >

</div>

</form>

</div>

<p> </p>

</body>

</html>

I need any help i can get.

Thanks,

Pino

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