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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.
Description of
Other Type of
License,
Registration,
Certification,
Permit or
Other
Authorization
State
Below the
Licensure (1) “Add a related
license…”
checkbox
Text Entry
If the checkbox is
selected the
Description of Other
Type of License is
displayed
This information is
only collected if the
action involved a
license or
certification that is
not the professional
license to practice.
State
State
Below
Licensure (1) Description of
Other Type of
License text
entry
Drop List
If the checkbox is
selected the State is
displayed
This information is
only collected if the
action involved a
license or
certification that is
not the professional
license to practice.
ID Number
State
Below
Licensure (1) Description of
Other Type of
License text
entry
Text Entry
If the checkbox is
selected the ID
Number is displayed
This information is
only collected if the
action involved a
license or
certification that is
not the professional
license to practice.
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
Specialty
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
“Description” if the
profession or field of
licensure requires
specialty
information.
Description
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.
“Description 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
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
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
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.
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
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?"
Other
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
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.
Country
State
Below "Is the
Drop List
Licensure (1) practitioner
affiliated with a
health care
entity?"
checkbox
Address
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.
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
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.
Describe the
State
type of
Licensure(1)
registration,
certification.
permit or other
authorization
affected by the
action.
Below Other
license or
certification
action
Text Entry
The field is displayed
if the user selects the
" Other license or
certification action "
option
Selecting the option
displays Describe
the type of
registration, State
and ID Number
fields.
State
State
Licensure(1)
Below Other
license or
certification
action
Drop List
The field is displayed
if the user selects the
" Other license or
certification action "
option
Selecting the option
displays Describe
the type of
registration, State
and ID Number
fields.
ID Number
State
Licensure(1)
Below Other
license or
certification
action
Text Entry
The field is displayed
if the user selects the
" Other license or
certification action "
option
Selecting the option
displays Describe
the type of
registration, State
and ID Number
fields.
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
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.
Label
PDF Name
(step)
Location
Response
Input Item
Is
State
reinstatement Licensure (2)
automatic after
this period of
time?
Below “How
long will it
remain in
effect?”
Is the adverse State
action
Licensure (2)
specified in this
report based
on the
subject’s
professional
competence or
conduct, which
adversely
affected, or
could have
adversely
affected, the
health or
welfare of
patient(s)?
Below “Is
Radio
reinstatement Buttons
automatic after
this period of
time?”
Date of Appeal State
Below Is the
Licensure (2) action on
appeal?
Radio
Buttons
Text Entry
Visibility Trigger
Other
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)
The fields are
displayed if the user
selects a license
profession of
Physician (MD),
Physician (DO) or
Dentist for the
practitioner in
Subject Information
Available options
are “Yes” and “No”
The field is displayed
if the user selects Yes
option for “Is the
action on appeal?”
State Changes
Label
PDF Name
Item Type
Trigger
OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy
State Licensure
Modal
When the user selects the link the modal is displayed
with the public burden statement content.
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 Title | State Licensure |
| Subject | NPDB report |
| Author | Health Resources and Services Administration |
| File Modified | 2020-11-19 |
| File Created | 2020-11-18 |