<?php

$mois['fr']=['','Janvier','Février','Mars','Avril','Mai','Juin','Juillet','Aout','Septembre','Octobre','Novembre','Décembre',];

$mois['us']=['','January','February','March','April','May','June','July','August','September','October','November','December',];

$province=["BAS-UELE", "ÉQUATEUR", "HAUT-KATANGA", "HAUT-LOMAMI", "HAUT-UELE", "ITURI", "KASAÏ", "KASAÏ CENTRAL", "KASAÏ ORIENTAL", "KINSHASA", "KONGO-CENTRAL", "KWANGO", "KWILU", "LOMAMI", "LUALABA", "MAI-NDOMBE", "MANIEMA", "MONGALA", "NORD-KIVU", "NORD-UBANGI", "SANKURU", "SUD-KIVU", "SUD-UBANGI", "TANGANYIKA", "TSHOPO", "TSHUAPA"];

$countries['us'] = array("Afghanistan", "Albania", "Algeria", "American Samoa", "Andorra", "Angola", "Anguilla", "Antarctica", "Antigua and Barbuda", "Argentina", "Armenia", "Aruba", "Australia", "Austria", "Azerbaijan", "Bahamas", "Bahrain", "Bangladesh", "Barbados", "Belarus", "Belgium", "Belize", "Benin", "Bermuda", "Bhutan", "Bolivia", "Bosnia and Herzegowina", "Botswana", "Bouvet Island", "Brazil", "British Indian Ocean Territory", "Brunei Darussalam", "Bulgaria", "Burkina Faso", "Burundi", "Cambodia", "Cameroon", "Canada", "Cape Verde", "Cayman Islands", "Central African Republic", "Chad", "Chile", "China", "Christmas Island", "Cocos (Keeling) Islands", "Colombia", "Comoros", "Congo", "Congo, the Democratic Republic of the", "Cook Islands", "Costa Rica", "Cote d'Ivoire", "Croatia (Hrvatska)", "Cuba", "Cyprus", "Czech Republic", "Denmark", "Djibouti", "Dominica", "Dominican Republic", "East Timor", "Ecuador", "Egypt", "El Salvador", "Equatorial Guinea", "Eritrea", "Estonia", "Ethiopia", "Falkland Islands (Malvinas)", "Faroe Islands", "Fiji", "Finland", "France", "France Metropolitan", "French Guiana", "French Polynesia", "French Southern Territories", "Gabon", "Gambia", "Georgia", "Germany", "Ghana", "Gibraltar", "Greece", "Greenland", "Grenada", "Guadeloupe", "Guam", "Guatemala", "Guinea", "Guinea-Bissau", "Guyana", "Haiti", "Heard and Mc Donald Islands", "Holy See (Vatican City State)", "Honduras", "Hong Kong", "Hungary", "Iceland", "India", "Indonesia", "Iran (Islamic Republic of)", "Iraq", "Ireland", "Israel", "Italy", "Jamaica", "Japan", "Jordan", "Kazakhstan", "Kenya", "Kiribati", "Korea, Democratic People's Republic of", "Korea, Republic of", "Kuwait", "Kyrgyzstan", "Lao, People's Democratic Republic", "Latvia", "Lebanon", "Lesotho", "Liberia", "Libyan Arab Jamahiriya", "Liechtenstein", "Lithuania", "Luxembourg", "Macau", "Macedonia, The Former Yugoslav Republic of", "Madagascar", "Malawi", "Malaysia", "Maldives", "Mali", "Malta", "Marshall Islands", "Martinique", "Mauritania", "Mauritius", "Mayotte", "Mexico", "Micronesia, Federated States of", "Moldova, Republic of", "Monaco", "Mongolia", "Montserrat", "Morocco", "Mozambique", "Myanmar", "Namibia", "Nauru", "Nepal", "Netherlands", "Netherlands Antilles", "New Caledonia", "New Zealand", "Nicaragua", "Niger", "Nigeria", "Niue", "Norfolk Island", "Northern Mariana Islands", "Norway", "Oman", "Pakistan", "Palau", "Panama", "Papua New Guinea", "Paraguay", "Peru", "Philippines", "Pitcairn", "Poland", "Portugal", "Puerto Rico", "Qatar", "Reunion", "Romania", "Russian Federation", "Rwanda", "Saint Kitts and Nevis", "Saint Lucia", "Saint Vincent and the Grenadines", "Samoa", "San Marino", "Sao Tome and Principe", "Saudi Arabia", "Senegal", "Seychelles", "Sierra Leone", "Singapore", "Slovakia (Slovak Republic)", "Slovenia", "Solomon Islands", "Somalia", "South Africa", "South Georgia and the South Sandwich Islands", "Spain", "Sri Lanka", "St. Helena", "St. Pierre and Miquelon", "Sudan", "Suriname", "Svalbard and Jan Mayen Islands", "Swaziland", "Sweden", "Switzerland", "Syrian Arab Republic", "Taiwan, Province of China", "Tajikistan", "Tanzania, United Republic of", "Thailand", "Togo", "Tokelau", "Tonga", "Trinidad and Tobago", "Tunisia", "Turkey", "Turkmenistan", "Turks and Caicos Islands", "Tuvalu", "Uganda", "Ukraine", "United Arab Emirates", "United Kingdom", "United States", "United States Minor Outlying Islands", "Uruguay", "Uzbekistan", "Vanuatu", "Venezuela", "Vietnam", "Virgin Islands (British)", "Virgin Islands (U.S.)", "Wallis and Futuna Islands", "Western Sahara", "Yemen", "Yugoslavia", "Zambia", "Zimbabwe");

$countries['fr'] = array("Afghanistan", "Albanie", "Algérie", "Samoa américaines", "Andorre", "Angola", "Anguilla", "Antarctique", "Antigua-et-Barbuda", "Argentine", "Arménie", "Aruba", "Australie", "Autriche", "Azerbaïdjan", "Bahamas", "Bahreïn", "Bangladesh", "Barbade", "Biélorussie", "Belgique", "Belize", "Bénin", "Bermudes", "Bhoutan", "Bolivie", "Bosnie-Herzégovine", "Botswana", "Île Bouvet", "Brésil", "Territoire britannique de l'océan Indien", "Brunei Darussalam", "Bulgarie", "Burkina Faso", "Burundi", "Cambodge", "Cameroun", "Canada", "Cap-Vert", "Îles Caïmans", "République Centrafricaine", "Tchad", "Chili", "Chine", "Christmas Island", "Cocos (Keeling )", "Colombie", "Comores", "République du Congo", "République Démocratique du Congo", "Îles Cook", "Costa Rica", "Côte d'Ivoire", "Croatie (Hrvatska)", "Cuba", "Chypre", "République tchèque", "Danemark", "Djibouti", "Dominique", "République dominicaine", "Timor oriental", "Équateur", "Égypte", "El Salvador", "Guinée Équatoriale","Erythrée", "Estonie", "Ethiopie", "Iles Falkland (Malvinas)", "Îles Féroé", "Fidji", "Finlande", "France", "France métropolitaine", "Guyane française", "Polynésie française", "Terres australes françaises", "Gabon", "Gambie" , "Géorgie", "Allemagne", "Ghana", "Gibraltar", "Grèce", "Groenland", "Grenade", "Guadeloupe", "Guam", "Guatemala", "Guinée", "Guinée-Bissau", "Guyane", "Haïti", "Îles Heard et Mc Donald", "État de la Cité du Vatican Saint-Siège", "Honduras", "Hong Kong", "Hongrie", "Islande", "Inde", "Indonésie", "République islamique d'Iran", "Irak", "Irlande", "Israël", "Italie", "Jamaïque", "Japon", "Jordanie", "Kazakhstan", "Kenya", "Kiribati", "République populaire démocratique de Corée", "République de Corée", "Koweït", "Kirghizistan", "République démocratique populaire Lao", "Lettonie", "Liban", "Lesotho", "Libéria", "Jamahiriya arabe libyenne", "Liechtenstein", "Lituanie", "Luxembourg", "Macao", "l'ex-République yougoslave de Macédoine", "Madagascar", "Malawi", "Malaisie", "Maldives", "Mali", "Malte", "Iles Marshall", "Martinique", "Mauritanie", "Maurice", "Mayotte", "Mexique", "États fédérés de Micronésie", "République de Moldavie", "Monaco", "Mongolie", "Montserrat", "Maroc", "Mozambique", "Myanmar" , "Namibie", "Nauru", "Népal", "Pays-Bas", "Antilles néerlandaises", "Nouvelle-Calédonie", "Nouvelle-Zélande", "Nicaragua", "Niger", "Nigeria", "Niue", "Norfolk Island", "Iles Mariannes du Nord", "Norvège", "Oman", "Pakistan", "Palaos", "Panama", "Papouasie-Nouvelle-Guinée", "Paraguay", "Pérou", "Philippines", "Pitcairn", "Pologne", "Portugal", "Porto Rico", "Qatar", "Réunion", "Roumanie", "Fédération de Russie", "Rwanda", "Saint-Kitts-et-Nevis", "Sainte-Lucie", "Saint-Vincent et les Grenadines", "Samoa", "Saint-Marin", "Sao Tomé", "Arabie saoudite", "Sénégal", "Seychelles", "Sierra Leone", "Singapour", "Slovaquie (République slovaque)" , "Slovénie", "Îles Salomon", "Somalie", "Afrique du Sud", "Géorgie du Sud et îles Sandwich du Sud", "Espagne", "Sri Lanka", "St. Hélène", "St. Pierre et Miquelon", "Soudan", "Suriname", "Îles Svalbard et Jan Mayen", "Swaziland", "Suède", "Suisse", "République arabe syrienne", "Taïwan", "Tadjikistan" , "Tanzanie", "Thaïlande", "Togo", "Tokelau", "Tonga", "Trinité-et-Tobago", "Tunisie", "Turquie", "Turkménistan", "Îles Turques et Caïques", "Tuvalu", "Ouganda", "Ukraine", "Émirats arabes unis", "Royaume-Uni", "États-Unis", "Îles mineures éloignées des États-Unis", "Uruguay", "Ouzbékistan", "Vanuatu", "Venezuela", "Vietnam", "Îles Vierges (britanniques)", "Îles Vierges (États-Unis)", "Îles Wallis et Futuna", "Sahara occidental", "Yémen", "Yougoslavie", "Zambie", "Zimbabwe");



?>

<style>

    .iti--allow-dropdown input, .iti--allow-dropdown input[type=text], .iti--allow-dropdown input[type=tel], .iti--separate-dial-code input, .iti--separate-dial-code input[type=text], .iti--separate-dial-code input[type=tel] {

    padding-right: 0px !important;

    padding-left: 52px;

    margin-left: 0; }

</style>

<div class="row"><div class="col text-center"></div></div>

<div class="row"><div class="col text-center">

    

    

</div></div>

<div class="row"><form id="form" class="col m-auto" style="max-width: 1200px; ">

    <?php include_once 'inc.header.php'?>

    <div class="card">

        <div class="card-body">

            <div class="row">

                <div class="form-group col-md-6">

                    <label for=""><?=translate('Nom')?> <span class="text-danger">*</span></label>

                    <input type="text" id="nom" name="nom" class="form-control" placeholder="<?=translate('Nom')?>">

                </div>

                <div class="form-group col-md-6">

                    <label for=""><?=translate('Prénom')?> <span class="text-danger">*</span></label>

                    <input type="text" id="prenom" name="prenom" class="form-control" placeholder="<?=translate('Prénom')?>">

                </div>

            </div>

            <div class="row">

                <div class="form-group col-md-6">

                    <label for=""><?=translate('Postnom')?> <span class="text-danger"></span></label>

                    <input type="text" id="postnom" name="postnom" class="form-control" placeholder="<?=translate('Postnom')?>">

                </div>

                <div class="form-group col-md-6">

                    <label for=""><?=translate('Genre')?> <span class="text-danger">*</span></label>

                    <select name="sexe" id="sexe" class="form-control">

                        <option value="-1" disabled selected><?=translate('Séléctionnez')?></option>

                        <option value="M"><?=translate('Masculin')?></option>

                        <option value="F"><?=translate('Féminin')?></option>

                    </select>

                </div>

            </div>

            <hr>

            <div class="row">

                <div class="col-md-4 form-group">

                    <label for=""><?=translate('Date de naissance')?></label>

                    <select name="jour_nais" id="jour_nais" class="form-control">

                        <option value="-1" disabled selected><?=translate('Jour')?></option>

                        <?php for($i=1;$i<=31;$i++) echo"<option>$i</option>" ?>

                    </select>

                </div>

                <div class="col-md-4 form-group">

                    <label for="">&nbsp;</label>

                    <select name="mois_nais" id="mois_nais" class="form-control">

                        <option value="-1" disabled selected><?=translate('Mois')?></option>

                        <?php for($i=1;$i<=12;$i++) echo"<option value=\"$i\">".$mois[$_lang][$i]."</option>" ?>

                    </select>

                </div>

                <div class="col-md-4 form-group">

                    <label for="">&nbsp;</label>

                    <select name="annee_nais" id="annee_nais" class="form-control">

                        <option value="-1" disabled selected><?=translate("Année")?></option>

                        <?php for($i=2020;$i>=1920;$i--) echo"<option>$i</option>" ?>

                    </select>

                </div>

            </div>

            <hr>

            <div class="row">

                <div class="col-md-6 form-group">

                    <label for=""><?=translate('Nationalité')?></label>

                    <select name="nationalite" id="nationalite" class="form-control">

                        <option value="-1" disabled selected><?=translate('Séléctionnez')?></option>

                        <?php for($i=0;$i<count($countries[$_lang]);$i++) echo"<option>{$countries[$_lang][$i]}</option>" ?>

                    </select>

                </div>

                <div class="col-md-6 form-group">

                    <label for=""><?=translate("Pays d'origine")?><span class="text-danger">*</span></label>

                    <select name="pays_origine" id="pays_origine" class="form-control">

                        <option value="-1" disabled selected><?=translate("Séléctionnez")?></option>

                        <?php for($i=0;$i<count($countries[$_lang]);$i++) echo"<option>{$countries[$_lang][$i]}</option>" ?>

                    </select>

                </div>

            </div>

            <hr>

            <div class="row">

                <div class="col-md-4 form-group">

                    <label for=""><?=translate("Date d'arrivée")?><span class="text-danger">*</span></label>

                    <select name="jour_arrivee" id="jour_arrivee" class="form-control">

                        <option value="-1" disabled selected><?=translate("Jour")?></option>

                        <?php for($i=1;$i<=31;$i++) echo"<option>$i</option>" ?>

                    </select>

                </div>

                <div class="col-md-4 form-group">

                    <label for="">&nbsp;</label>

                    <select name="mois_arrivee" id="mois_arrivee" class="form-control">

                        <option value="-1" disabled selected><?=translate("Mois")?></option>

                        <?php for($i=1;$i<=12;$i++) echo"<option value=\"$i\">".$mois[$_lang][$i]."</option>" ?>

                    </select>

                </div>

                <div class="col-md-4 form-group">

                    <label for="">&nbsp;</label>

                    <select name="annee_arrivee" id="annee_arrivee" class="form-control">

                        <option value="-1" disabled selected><?=translate("Année")?></option>

                        <?php for($i=date('Y');$i<=date('Y')+1;$i++) echo"<option>$i</option>" ?>

                    </select>

                </div>

            </div>

            <hr>

            <div class="row">

                <div class="form-group col-md-4 ">

                    <label for=""><?=translate("N° Passeport")?> <span class="text-danger">*</span></label>

                    <input name="num_passeport" id="num_passeport" type="text" class="form-control" placeholder="<?=translate("Numéro de passeport")?>">

                </div>

                <div class="form-group col-md-4 __b">

                    <input type="hidden" name="telephone" id="telephone">

                    <label for=""><?=translate("Télephone")?> <span class="text-danger">*</span></label><br>

                    <input name="tel" id="tel" type="text" class="form-control" placeholder="<?=translate("Téléphone")?>">

                </div>

                <div class="form-group col-md-4">

                    <label for=""><?=translate("Adresse mail")?> <span class="text-danger">*</span></label>

                    <input name="email" id="email" type="text" class="form-control" placeholder="<?=translate("Adresse mail")?>">

                </div>

            </div>

            <div class="row">

                <div class="form-group col-md-3">

                    <label for=""><?=translate("Moyen de Transport")?> <span class="text-danger">*</span></label>

                    <select name="voie_transport" id="voie_transport" class="form-control">

                        <option value="-1" disabled selected><?=translate("Séléctionnez")?></option>

                        <option value="Voie aérienne"><?=translate('Voie Aérienne')?></option>

                        <option value="Voie terrestre"><?=translate('Voie Terrestre')?></option>

                        <option value="Voie maritime"><?=translate('Voie Maritime')?></option>

                    </select>

                </div>

                <div class="form-group col-md-3">

                    <label for=""><?=translate("Compagnies")?> <span class="text-danger">*</span></label>

                    <input type="hidden" name="compagnie" id="compagnie" data-target="">

                    <select id="comp" name="comp" class="d-none comp form-control" onchange="$('#compagnie').val($(this).val())">

                        <option value="-1" disabled selected><?=translate("Séléctionnez")?></option>

                        <?php airlines() ?>

                    </select>

                    <input id="comp_" name="comp_" type="text" onchange="$('#compagnie').val($(this).val())" placeholder="<?=translate("Compagnies")?>" class="form-control comp">

                </div>

                <div class="form-group col-md-3">

                    <label for=""><?=translate("N° Vol")?> <span class="text-danger">*</span></label>

                    <input name="num_vol" id="num_vol" type="text" class="form-control" placeholder="<?=translate("N° Vol")?>">

                </div>

                <div class="form-group col-md-3">

                    <label for=""><?=translate("N° Siège")?> <span class="text-danger">*</span></label>

                    <input name="num_siege" id="num_siege" type="text" class="form-control" placeholder="<?=translate("N° Siège")?>">

                </div>

            </div>

            <hr>

            <div class="row">

                <div class="form-group col-md-4">

                    <label for=""><?=translate("Province de destination")?> <span class="text-danger">*</span></label>

                    <select name="province" id="province" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <?=combobox(['array'=>$province])?>

                    </select>

                </div>

                <div class="form-group col-md-4">

                    <label for=""><?=translate("Ville de destination")?> <span class="text-danger"></span></label>

                    <input name="destination" id="destination" type="text" class="form-control" placeholder="<?=translate("Ville de destination")?>">

                </div>

                <div class="form-group col-md-4">

                    <label for=""><?=translate("Dernier pays visité")?> <span class="text-danger"></span></label>

                    <select name="pays_visite" id="pays_visite" class="form-control">

                        <option value="-1" disabled selected><?=translate("Dernier pays visité")?></option>

                        <?php for($i=0;$i<count($countries[$_lang]);$i++) echo"<option>{$countries[$_lang][$i]}</option>" ?>

                    </select>

                </div>

            </div>

            <hr>

            <div class="row">

                <div class="form-group col-md-6">

                    <label for=""><?=translate("Avez-vous de la fièvre? (Au-délà 37°)")?> <span class="text-danger">*</span></label>

                    <select name="fievre" id="fievre" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <option value="1"><?=translate("OUI")?></option>

                        <option value="0"><?=translate("NON")?></option>

                    </select>

                </div>

                <div class="form-group col-md-6">

                    <label for=""><?=translate("Avez-vous une sensation de fièvre ?")?> <span class="text-danger">*</span></label>

                    <select name="sensation_fievre" id="sensation_fievre" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <option value="1"><?=translate("OUI")?></option>

                        <option value="0"><?=translate("NON")?></option>

                    </select>

                </div>



            </div>

            <div class="row">

                <div class="form-group col-md-6">

                    <label for=""><?=translate("Avez-vous passé le test Covid-19 ?")?> <span class="text-danger">*</span></label>

                    <select name="test_covid" id="test_covid" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <option value="1"><?=translate("OUI")?></option>

                        <option value="0"><?=translate("NON")?></option>

                    </select>

                </div>

                <div class="form-group col-md-6">

                    <label for=""><?=translate("Avez-vous des frissons ?")?> <span class="text-danger">*</span></label>

                    <select name="frisson" id="frisson" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <option value="1"><?=translate("OUI")?></option>

                        <option value="0"><?=translate("NON")?></option>

                    </select>

                </div>

            </div>

            <div class="row">

                <div class="form-group col-md-6">

                    <label for=""><?=translate("Toussez-vous ?")?> <span class="text-danger">*</span></label>

                    <select name="toux" id="toux" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <option value="1"><?=translate("OUI")?></option>

                        <option value="0"><?=translate("NON")?></option>

                    </select>

                </div>

                <div class="form-group col-md-6">

                    <label for=""><?=translate("Avez-vous des difficultés respiratoires ?")?> <span class="text-danger">*</span></label>

                    <select name="difficulte_respiratoire" id="difficulte_respiratoire" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <option value="1"><?=translate("OUI")?></option>

                        <option value="0"><?=translate("NON")?></option>

                    </select>

                </div>

            </div>

            <hr>

            <input type="hidden" name="langue" id="langue" value="<?=$_lang?>">

            <div class="row">

                <div class="form-group col-md-8">

                    <label for=""><?=translate("Adresse complète")?> <span class="text-danger">*</span></label>

                    <input name="adresse" id="adresse" type="text" class="form-control" placeholder="<?=translate("Indiquez l'adresse où vous sejournez au Congo")?>">

                </div>

                <div class="form-group col-md-4">

                    <label for=""><?=translate("Avez-vous une assurance maladie ?")?> <span class="text-danger">*</span></label>

                    <select name="assurance_maladie" id="assurance_maladie" class="form-control">

                        <option value="-1" disabled selected><?=translate("Choisissez")?></option>

                        <option value="1"><?=translate("OUI")?></option>

                        <option value="0"><?=translate("NON")?></option>

                    </select>

                </div>

            </div>

            <div class="form-group text-center"></div>

        </div>

        <div class="card-footer text-center"><button type="submit" class="btn-lg btn btn-outline-danger"><?=translate("Soumettre")?></button></div>

    </div>



</form></div>

<script>

    var err_msg={

        email: {

          required: "<?=translate("Veuillez remplir le champ")?>",

          email: "<?=translate("Veuillez entrer une adresse mail correcte")?>"

        },

        nom: {

            required: "<?=translate("Veuillez remplir le champ")?>"

        },

        prenom: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        sexe: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        jour_nais: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        annee_nais: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        mois_nais: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        nationalite: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        pays_origine: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        jour_arrivee: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        annee_arrivee: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

          mois_arrivee: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        num_passeport: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        tel: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        compagnie: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        num_vol: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        num_siege: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        fievre: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        sensation_fievre: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        test_covid: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        frisson: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        toux: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        assurance_maladie: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        province: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        voie_transport: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        difficulte_respiratoire: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        },

        adresse: {

          required: "<?=translate("Veuillez remplir le champ")?>"

        }

      }

</script>