<div class="questionrow">
	<div class="question">Reimbursement Head Code</div>
	<div class="answer">
		<input type="text" name="reimbrsmnt_head_code" id="reimbrsmnt_head_code" value="<?php echo $reimbrsmnt_head_code; ?>" readonly />
		<input type="hidden" name="id" id="id" value="<?php echo $id; ?>"/>
	</div>
</div>
<div class="clear_form">
</div>
<div class="questionrow">
	<div class="question">Reimbursement Head Name</div>
	<div class="answer">
		<input type="text" name="reimbrsmnt_head_name" id="reimbrsmnt_head_name" value="<?php echo $reimbrsmnt_head_name; ?>" />
	</div>
</div>
<div class="clear_form">
</div>
<div class="questionrow">
	<div class="question">Status</div>
	<div class="answer">
		<input type="checkbox" name="status" id="status" value="Y" <?php echo $status_chk; ?> />
	</div>
</div>
<div class="clear_form">
</div>
<div class="questionrow">
	<div style="padding: 5px;" align="center">
		<input type="submit" name="Submit" value="Submit" />
	</div>
</div>