     <h4>OHIS</h4>
        <div class="form-group">
          <div class="col-md-12">
              <h5>Debris Index</h5>
              <div class="form-inline">
                  <div class="form-group">
                      <input type="text" name="d_16" class="form-control" placeholder="16"/>
                  </div>
                  <div class="form-group">
                      <input type="text" name="d_11" class="form-control" placeholder="11"/>
                  </div>
                  <div class