\documentclass[
	a4paper,
	10pt]{article}

\usepackage[
	top=2.5cm,
	bottom=2.5cm,
	left=2cm,
	right=2cm
]{geometry}

\usepackage{booktabs} % table midrule


\usepackage[most]{tcolorbox}
\usepackage{hyperref}
\usepackage{float}

% Question formatting
\newdimen\longline
\longline=\linewidth\advance\longline+0cm

\def\LayoutTextField#1#2{#2}

\def\lbl#1{\hbox to 4cm{#1\hfill\strut}}%
\def\labelline#1#2{\lbl{#1}\vbox{\hbox{\raisebox{-1.0\baselineskip}{\TextField[name=#1,width=#2]{\null}}}\kern2pt{\hbox to \longline{\leaders\hbox to 5pt{\hss . \hss}\hfil}}}}

\def\q#1{\hbox to \hsize{\labelline{#1}{\longline}}\vskip0.5ex}

\begin{document}

\thispagestyle{empty}

\begin{Form}
\begin{tcolorbox}[colback=white,colframe=black,colbacktitle=black!10!white, coltitle=black,title={Model name: \raisebox{-0.25\baselineskip}{\TextField[name=title, width=12em]{}}}]
	\subsection*{Contact Details}

		\q{Developers}
		\q{Institution}
		\q{Contact email}
			
	\tcbline
			  
	\subsection*{Model Details}
		\q{Link to source code}
		\q{Citation details}
		\q{Model description}
		\q{ }
			
	\tcbline
			
	\subsection*{Results}
 		\begin{table}[H]
			\centering
			\begin{tabular}{l|r|cccc|cccc}
				\multicolumn{10}{c}{\textit{Performance of a subject-specific model}} \\
				\midrule
				\multicolumn{2}{r|}{Metrics} & \multicolumn{4}{c|}{Event-based} & \multicolumn{4}{c}{Sample-based} \\
				\multicolumn{2}{l|}{} & CHB-MIT & TUH & Siena & SeizeIT & CHB-MIT  & TUH & Siena & SeizeIT \\
				\midrule
				\multicolumn{2}{r|}{F1-score}        & \TextField[name = ps.e.f1.chb,width=2.5em]{}  & -  & \TextField[name = ps.e.f1.siena,width=2.5em]{} & \TextField[name = ps.e.f1.sz,width=2.5em]{} & \TextField[name = ps.s.f1.chb,width=2.5em]{}  & -  & \TextField[name = ps.s.f1.siena,width=2.5em]{} & \TextField[name = ps.s.f1.sz,width=2.5em]{} \\
				\multicolumn{2}{r|}{Sensitivity}     & \TextField[name = ps.e.s.chb,width=2.5em]{}   & -  & \TextField[name = ps.e.s.siena,width=2.5em]{}  & \TextField[name = ps.e.s.sz,width=2.5em]{}  & \TextField[name = ps.s.s.chb,width=2.5em]{}   & -  & \TextField[name = ps.s.s.siena,width=2.5em]{}  & \TextField[name = ps.s.s.sz,width=2.5em]{}  \\
				\multicolumn{2}{r|}{Precision}       & \TextField[name = ps.e.p.chb,width=2.5em]{}   & -  & \TextField[name = ps.e.p.siena,width=2.5em]{}  & \TextField[name = ps.e.p.sz,width=2.5em]{}  & \TextField[name = ps.s.p.chb,width=2.5em]{}   & -  & \TextField[name = ps.s.p.siena,width=2.5em]{}  & \TextField[name = ps.s.p.sz,width=2.5em]{}  \\
				\multicolumn{2}{r|}{FP rate}         & \TextField[name = ps.e.fp.chb,width=2.5em]{}  & -  & \TextField[name = ps.e.fp.siena,width=2.5em]{} & \TextField[name = ps.e.fp.sz,width=2.5em]{} & \TextField[name = ps.s.fp.chb,width=2.5em]{}  & -  & \TextField[name = ps.s.fp.siena,width=2.5em]{} & \TextField[name = ps.s.fp.sz,width=2.5em]{} \\
				\midrule
				\midrule
				\multicolumn{10}{c}{\textit{Performance of a subject-independent model cross-validated on a single dataset}} \\
				\midrule
				\multicolumn{2}{r|}{Metrics} & \multicolumn{4}{c|}{Event-based} & \multicolumn{4}{c}{Sample-based} \\
				\multicolumn{2}{l|}{} & CHB-MIT & TUH & Siena & SeizeIT & CHB-MIT  & TUH & Siena & SeizeIT \\
				\midrule
				\multicolumn{2}{r|}{F1-score}    & \TextField[name = pi.e.f1.chb,width=2.5em]{}  & \TextField[name = pi.e.f1.tuh,width=2.5em]{} & \TextField[name = pi.e.f1.siena,width=2.5em]{} & \TextField[name = pi.e.f1.sz,width=2.5em]{} & \TextField[name = pi.s.f1.chb,width=2.5em]{}  & \TextField[name = pi.s.f1.tuh,width=2.5em]{}  & \TextField[name = pi.s.f1.siena,width=2.5em]{} & \TextField[name = pi.s.f1.sz,width=2.5em]{} \\
				\multicolumn{2}{r|}{Sensitivity} & \TextField[name = pi.e.s.chb,width=2.5em]{}   & \TextField[name = pi.e.s.tuh,width=2.5em]{}  & \TextField[name = pi.e.s.siena,width=2.5em]{}  & \TextField[name = pi.e.s.sz,width=2.5em]{}  & \TextField[name = pi.s.s.chb,width=2.5em]{}   & \TextField[name = pi.s.s.tuh,width=2.5em]{}  & \TextField[name = pi.s.s.siena,width=2.5em]{}  & \TextField[name = pi.s.s.sz,width=2.5em]{}  \\
				\multicolumn{2}{r|}{Precision}   & \TextField[name = pi.e.p.chb,width=2.5em]{}   & \TextField[name = pi.e.p.tuh,width=2.5em]{}  & \TextField[name = pi.e.p.siena,width=2.5em]{}  & \TextField[name = pi.e.p.sz,width=2.5em]{}  & \TextField[name = pi.s.p.chb,width=2.5em]{}   & \TextField[name = pi.s.p.tuh,width=2.5em]{}  & \TextField[name = pi.s.p.siena,width=2.5em]{}  & \TextField[name = pi.s.p.sz,width=2.5em]{}  \\
				\multicolumn{2}{r|}{FP rate}     & \TextField[name = pi.e.fp.chb,width=2.5em]{}  & \TextField[name = pi.e.fp.tuh,width=2.5em]{} & \TextField[name = pi.e.fp.siena,width=2.5em]{} & \TextField[name = pi.e.fp.sz,width=2.5em]{} & \TextField[name = pi.s.fp.chb,width=2.5em]{}  & \TextField[name = pi.s.fp.tuh,width=2.5em]{}  & \TextField[name = pi.s.fp.siena,width=2.5em]{} & \TextField[name = pi.s.fp.sz,width=2.5em]{} \\
				\midrule
				\midrule
				\multicolumn{10}{c}{\textit{Performance of a subject-independent model trained on a independent dataset}} \\
				\midrule
				Training  & Metrics & \multicolumn{4}{c|}{Event-based} & \multicolumn{4}{c}{Sample-based} \\
				Data                              &             & CHB-MIT                                    & TUH                                        & Siena                                        & SeizeIT                                   & CHB-MIT                                    & TUH                                        & Siena                                        & SeizeIT                                   \\
				\midrule
				\TextField[name = di,width=2.5em]{} & F1-score    & \TextField[name = di.e.f1.chb,width=2.5em]{} & \TextField[name = di.e.f1.tuh,width=2.5em]{} & \TextField[name = di.e.f1.siena,width=2.5em]{} & \TextField[name = di.e.f1.sz,width=2.5em]{} & \TextField[name = di.s.f1.chb,width=2.5em]{} & \TextField[name = di.s.f1.tuh,width=2.5em]{} & \TextField[name = di.s.f1.siena,width=2.5em]{} & \TextField[name = di.s.f1.sz,width=2.5em]{} \\
				                                  & Sensitivity & \TextField[name = di.e.s.chb,width=2.5em]{}  & \TextField[name = di.e.s.tuh,width=2.5em]{}  & \TextField[name = di.e.s.siena,width=2.5em]{}  & \TextField[name = di.e.s.sz,width=2.5em]{}  & \TextField[name = di.s.s.chb,width=2.5em]{}  & \TextField[name = di.s.s.tuh,width=2.5em]{}  & \TextField[name = di.s.s.siena,width=2.5em]{}  & \TextField[name = di.s.s.sz,width=2.5em]{}  \\
				                                  & Precision   & \TextField[name = di.e.p.chb,width=2.5em]{}  & \TextField[name = di.e.p.tuh,width=2.5em]{}  & \TextField[name = di.e.p.siena,width=2.5em]{}  & \TextField[name = di.e.p.sz,width=2.5em]{}  & \TextField[name = di.s.p.chb,width=2.5em]{}  & \TextField[name = di.s.p.tuh,width=2.5em]{}  & \TextField[name = di.s.p.siena,width=2.5em]{}  & \TextField[name = di.s.p.sz,width=2.5em]{}  \\
				                                  & FP rate     & \TextField[name = di.e.fp.chb,width=2.5em]{} & \TextField[name = di.e.fp.tuh,width=2.5em]{} & \TextField[name = di.e.fp.siena,width=2.5em]{} & \TextField[name = di.e.fp.sz,width=2.5em]{} & \TextField[name = di.s.fp.chb,width=2.5em]{} & \TextField[name = di.s.fp.tuh,width=2.5em]{} & \TextField[name = di.s.fp.siena,width=2.5em]{} & \TextField[name = di.s.fp.sz,width=2.5em]{} \\
			\end{tabular}
		\end{table}
\end{tcolorbox}
\end{Form}

\end{document}
