Form 18 One Time Query for an Organization

Non-visible Questions
Label

Organization
Description

PDF Name (step) Location

Response Visibility
Input
Trigger
Item

Other

One Time Query
for an
Organization (1)

Below
Text
Organization Entry
Type

The field is
displayed if the
user selects an
organization
type that
requires a
description.

FDA (Federal
One Time Query
Food and Drug for an
Administration) Organization (1)

Below
Text
checkbox
Entry
"Does the
subject have
a FDA or
CLIA
identification
number?"

The field is
displayed if the
user selects the
checkbox for
"Does the
subject have a
FDA or CLIA
identification
number?"

Selecting the
checkbox displays
FDA and CLIA text
entry fields.

CLIA (Clinical
Laboratory
Improvement
Act)

Below FDA
text entry

Text
Entry

The field is
displayed if the
user selects the
checkbox for
"Does the
subject have a
FDA or CLIA
identification
number?"

Selecting the
checkbox displays
FDA and CLIA text
entry fields.

After step 1
Subject
Information

Check
boxes

Entity Selection
is only
displayed if the
entity is
authorized to
act as an agent
to query on
behalf of other
entities.

All entities are
listed for which the
user is authorized
to query.

One Time Query
for an
Organization (1)

Entity Selection One Time Query
for an
Organization (2)

State Changes
Label

PDF Name

Item Type

Trigger

Public
Burden
Statement

One Time Query Modal
for an
Organization

When the user selects the Public
Burden Statement link the modal is
displayed.

License
Number

One Time Query Text Entry
for an
Organization

The field is disabled if the user selects
the "No/ Not sure" option for "Does
the organization have a license?"