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physical_impairments_completed.html
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physical_impairments_completed.html
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<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<script src="./jquery-ui/external/jquery/jquery.js"></script>
<script src="./jquery.countdown.min.js"></script>
<!-- Latest compiled and minified CSS -->
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/css/bootstrap.min.css" integrity="sha384-BVYiiSIFeK1dGmJRAkycuHAHRg32OmUcww7on3RYdg4Va+PmSTsz/K68vbdEjh4u" crossorigin="anonymous">
<!-- Optional theme -->
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/css/bootstrap-theme.min.css" integrity="sha384-rHyoN1iRsVXV4nD0JutlnGaslCJuC7uwjduW9SVrLvRYooPp2bWYgmgJQIXwl/Sp" crossorigin="anonymous">
<style>
.form {
margin-bottom: 20px;
margin-top: 20px;
}
body{
text-align: left;
font-family: sans-serif;
font-weight: 100;
padding: 100px;
}
h1{
color: #396;
font-weight: 100;
font-size: 40px;
margin: 40px 0px 20px;
}
form {
width: 50%;
}
</style>
</head>
<body>
<h1 tabindex="0">Personal Information</h1>
<h4 tabindex="1"> Time Remaining: <span id="clock"></span> minutes</h4>
<!--- Roles: https://www.w3.org/wiki/PF/XTech/HTML5/RoleAttribute -->
<!-- Menu Items, ARIA Role and Tab Index -->
<form class="form" action="/" method="get">
<h3>Name Information</h3>
<div class="form-group">
<label for="firstName">First Name</label>
<input role="textbox" tabindex="2" class="form-control" type="text" id="firstName" name="first-name" aria-required="true" aria-label="type your first name" />
</div>
<div class="form-group">
<label for="middleName">Middle Name</label>
<input role="textbox" tabindex="3" class="form-control" type="text" id="middleName" name="middle-name" aria-required="true" aria-label="type your middle name" />
</div>
<div class="form-group">
<label for="lastName">Last Name</label>
<input role="textbox" tabindex="4" class="form-control" type="text" id="lastName" name="last-name" aria-required="true" aria-label="type your last name" />
</div>
<div class="form-group">
<label for="maidenName">Maiden Name (if applicable)</label>
<input role="textbox" tabindex="5" class="form-control" type="text" id="maidenName" name="maiden-name" aria-required="false" aria-label="type your maiden name" />
</div>
<h3>Address Information</h3>
<div class="form-group">
<label for="streetAddress">Street Address</label>
<input role="textbox" tabindex="6" class="form-control" type="text" id="streetAddress" name="street-address" aria-required="true" aria-label="type your street address" />
</div>
<div class="form-group">
<label for="aptOrSuite">Apt or Suite # (if applicable)</label>
<input role="textbox" tabindex="7" class="form-control" type="text" id="aptOrSuite" name="apt-or-suite" aria-required="false" aria-label="type your apartment or suite number" />
</div>
<div class="form-group">
<label for="city">City</label>
<input role="textbox" tabindex="8" class="form-control" type="text" id="city" name="city" aria-required="true" aria-label="type your city" />
</div>
<div class="form-group">
<label for="state">State</label>
<input role="textbox" tabindex="9" class="form-control" type="text" id="state" name="state" aria-required="true" aria-label="type your state" />
</div>
<div class="form-group">
<label for="country">Country</label>
<input role="textbox" tabindex="10" class="form-control" type="text" id="country" name="country" aria-required="true" aria-label="type your country" />
</div>
<div class="form-group">
<label for="zipCode">Zip/Postal Code</label>
<input role="textbox" tabindex="11" class="form-control" type="text" id="zipCode" name="zip-code" aria-required="true" aria-label="type your zip or postal code" />
</div>
<button tabindex="12" type="submit" class="btn btn-default">Submit</button>
</form>
<script>
let tenminutes = new Date();
tenminutes.setMinutes(tenminutes.getMinutes() + 10);
$('#clock').countdown(tenminutes, function(event) {
$(this).html(event.strftime('%M:%S'));
});
</script>
</body>
</html>