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pdf Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
Date of Death
State
Below "Is this
Licensure (1) person
deceased?"
Text Entry The field is displayed
if the user selects the
"Yes" radio button for
"Is this person
deceased?"
Organization
Description
State
Below
Licensure (1) Organization
Type
Text Entry
The field is displayed
if the user selects an
organization type
that requires a
description.
Other Name
for Profession
State
Beside
Licensure (1) Profession or
Field of
Licensure
Text entry
The field is displayed
if the user selects a
profession or field of
licensure that
requires a
description.
“Specialty” is
displayed in place of
“Other Name” for
Occupation if the
profession or field of
licensure requires
specialty
information.
Specialty
State
Beside
Licensure (1) Profession or
Field of
Licensure
Drop List
The field is displayed
if the user selects a
profession or field of
licensure that
requires information
for specialty.
“Other Name for
Profession” is
displayed in place of
“Specialty” if the
profession or field of
licensure does not
require information
for specialty.
FEIN (Federal
Employer
Identification
Number)
State
Below
Text Entry
Licensure (1) checkbox
"Does the
subject have an
FEIN, or UPIN
identification
number?"
The field is displayed
in the individual
report form if the
user selects the
checkbox for "Does
the subject have an
FEIN, or UPIN
identification
number?"
Selecting the
checkbox displays
FEIN and UPIN text
entry fields.
UPIN (Unique
Physician
Identification
Numbers)
State
Below FEIN
Licensure (1) text entry
Text Entry
The field is displayed
in the individual
report form if the
user selects the
checkbox for "Does
the subject have an
FEIN, or UPIN
identification
number?"
Selecting the
checkbox displays
FEIN and UPIN text
entry fields.
Text Entry
The field is displayed
in the organization
report form if the
user selects the
checkbox for "Does
the subject have a
FDA or CLIA
identification
number?"
Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.
CLIA (Clinical
Laboratory
Improvement
Act)
State
Below text
Text Entry
Licensure (1) entry FDA
(Federal Food
and Drug
Administration)
The field is displayed
in the organization
report form if the
user selects the
checkbox for "Does
the subject have a
FDA or CLIA
identification
number?"
Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.
Type of
Affiliation
State
Below "Is the
Drop List
Licensure (1) practitioner
affiliated with a
health care
entity?"
checkbox
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
FDA (Federal
State
Below
Food and Drug Licensure (1) checkbox
Administration)
"Does the
subject have a
FDA or CLIA
identification
number?"
Entity Name
State
Below Type of
Licensure (1) Affiliation
Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Country
State
Below "Is the
Drop List
Licensure (1) practitioner
affiliated with a
health care
entity?"
checkbox
Address
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries. United
States is the default
selection.
State
Below Country
Licensure (1)
Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Address Line 2
State
Below Address
Licensure (1)
Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
City
State
Below Address Text Entry
Licensure (1) Line 2
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
State
State
Below City
Licensure (1)
Drop List
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
ZIP
State
Below State
Licensure (1)
Text Entry The field is displayed
if the user selects the
"Is the practitioner
affiliated with a
health care entity?"
checkbox
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Was the action State
Below Adverse Radio
taken against a Licensure (2) Action(s) Taken buttons
multi-state
license?
The fields are
displayed if the user
selects a type of
professional license
that has a multi-state
license. Options are
“Yes” and “No”
If the selected
profession does not
have a multi-state
license then this
option is not
displayed.
Select up to 5
actions
State
Below “Was
Check
Licensure (2) the action
Boxes
taken against a
multi-state
license?”
The appropriate
fields are displayed
when the user selects
a radio button for
“Was the action
taken against a multistate license?”
If the selected
profession does not
have a multi-state
license then the
fields are not
hidden.
Description
State
Below an
Licensure (2) action
requiring a
description
Text Entry
The field is displayed
if the user selects an
action that requires a
description.
Description
State
Below Basis of
Licensure (2) Action(s)
Text Entry
The field is displayed
if the user selects a
basis of action that
requires a
description.
Period of time
number
State
Below “How
Licensure (2) long will it
remain in
effect?”
Text Entry
The field is displayed
if the user selects “A
specific period of
time” option for
“How long will it
remain in effect?”
Selecting the radio
button displays the
number text entry
and type of time
period drop list.
Period of time
type
State
Below “How
Licensure (2) long will it
remain in
effect?”
Drop List
The field is displayed
if the user selects “A
specific period of
time” option for
“How long will it
remain in effect?”
Selecting the radio
button displays the
number text entry
and type of time
period drop list.
Radio
Buttons
The fields are
displayed if the user
selects “A specific
period of time” for “Is
reinstatement
automatic after this
period of time?
Available options
are “No,” “Yes” and
“Yes with conditions
(Requires a Revision
to Action report
when status
changes)
Text Entry
The field is displayed
if the user selects Yes
option for “Is the
action on appeal?”
Is
State
reinstatement Licensure (2)
automatic after
this period of
time?
Below “How
long will it
remain in
effect?”
Date of Appeal State
Below Is the
Licensure (2) action on
appeal?
State Changes
Label
PDF Name
Item Type
Trigger
Public Burden
Statement
State Licensure
Modal
When the user selects the Public Burden Statement
link the modal is displayed.
Select a
Profession or
Field of
Licensure
State Licensure
Modal
When the user sets focus on the Profession or Field of
Licensure text entry, the modal to select a profession
is displayed and focus is set on the Search text
entry. The user can enter text in the Search text box
to find a specific profession or select a profession
from the list without searching. The modal is hidden
once the user selects a profession from the list. The
user's selection populates the Profession or Field of
Licensure text entry.
License
Number
State Licensure
Text Entry
Text entry is disabled if the user selects the "No/ Not
sure" option for "Does the subject have a license for
the selected profession or field of licensure?"
Select a Basis
for Action
State Licensure
Modal
When the user sets focus on the Basis for Action(s)
text entry, the modal to select an act is displayed and
focus is set on the Search text entry. The user can
enter text in the Search text box to find a
specific basis or select a basis from the list without
searching. The modal is hidden once the user selects
a basis from the list. The user's selection populates
the Basis for Action(s) text entry.
| File Type | application/pdf |
| File Modified | 2017-11-09 |
| File Created | 2017-09-25 |