    <p></p>

    <label for='alere_pima_cd4_file'>File</label>&nbsp;
    <input type="file" name="alere_pima_cd4_file" id="alere_pima_cd4_file"/>
    &nbsp;&nbsp;
    <label for='alere_pima_cd4_format'>Format</label>&nbsp;
    <select name="alere_pima_cd4_format" id="alere_pima_cd4_format">
        <option value='slk'>SLK</option>
    </select>
    <p></p>
    <h3>Advanced options</h3>
    <table cellpadding="0" cellspacing="0">
        <tr>
            <td><label for="alere_pima_cd4_artoapply">Analysis Requests state</label>&nbsp;</td>
            <td>
                <select name="alere_pima_cd4_artoapply" id="alere_pima_cd4_artoapply">
                    <option value="received">Received</option>
                    <option value="received_tobeverified">Received and to be verified</option>
                </select>
            </td>
        </tr>
        <tr>
            <td><label for="alere_pima_cd4_file_override">Results override</label></td>
            <td>
                <select name="alere_pima_cd4_override" id="alere_pima_cd4_file_override">
                    <option value="nooverride">Don't override results</option>
                    <option value="override">Override non-empty results</option>
                    <option value="overrideempty">Override non-empty results (also with empty)</option>
                </select>
            </td>
        </tr>
    </table>
    <p></p>
    <input name="firstsubmit" type="submit" value="Submit" i18n:attributes="value"/>
    <p></p>
