discourse/app/assets/javascripts/admin/templates/components/screened-ip-address-form.hbs

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<b>{{i18n 'admin.logs.screened_ips.form.label'}}</b>
{{text-field value=ip_address disabled=formSubmitted class="ip-address-input" placeholderKey="admin.logs.screened_ips.form.ip_address" autocorrect="off" autocapitalize="off"}}
{{combo-box content=actionNames value=actionName}}
{{d-button action="submit" disabled=formSubmitted label="admin.logs.screened_ips.form.add"}}