7 Title IV Clinical Privileges Actions_0915-0126

Non-visible Questions
Label
Date of Death

PDF Name
(step)
Title IV
Clinical
Privileges
Actions (1)

Location
Below "Is this
person
deceased?"

Response
Visibility Trigger
Input Item
Text Entry The field is displayed
if the user selects
the "Yes" radio
button for "Is this
person deceased?"
Text Entry The field is displayed
if the user selects an
organization type
that requires a
description.
Text entry The field is displayed
if the user selects a
profession or field of
licensure that may
use a description.

Organization
Description

Title IV
Clinical
Privileges
Actions (1)

Below
Organization
Type

Description

Title IV
Clinical
Privileges
Actions (1)

Beside
Profession or
Field of
Licensure

Specialty

Title IV
Clinical
Privileges
Actions (1)

Beside
Profession or
Field of
Licensure

Drop List

FEIN (Federal
Employer
Identification
Number)

Title IV
Clinical
Privileges
Actions (1)

Text Entry

UPIN (Unique
Physician
Identification
Numbers)

Title IV
Clinical
Privileges
Actions (1)

Below
checkbox
"Does the
subject have
an FEIN, or
UPIN
identification
number?"
Below FEIN
text entry

Text Entry

Other

“Specialty” is
displayed in place
of “Description“ if
the selected
profession or field
of
licensure requires
specialty
information.
The field is displayed “Description” is
if the user selects a
displayed in place
profession or field of of “Specialty” if the
licensure that
selected profession
requires information or field of licensure
for specialty.
does not require
information for a
specialty.
The field is displayed Selecting the
if the user selects
checkbox displays
the checkbox
FEIN and UPIN text
for "Does the subject entry fields.
have an FEIN, or
UPIN identification
number?"
The field is displayed
if the user selects
the checkbox for
"Does the subject
have an FEIN, or

Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Type of
Affiliation

Title IV
Clinical
Privileges
Actions (1)

Below "Is the
practitioner
affiliated with
a health care
entity?"
checkbox

Drop List

Entity Name

Title IV
Clinical
Privileges
Actions (1)

Below Type of
Affiliation

Text Entry The field is displayed
if the user selects
the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

Country

Title IV
Clinical
Privileges
Actions (1)

Below "Is the
practitioner
affiliated with
a health care
entity?"
checkbox

Drop List

Address

Title IV
Clinical
Privileges
Actions (1)

Below
Country

Text Entry The field is displayed
if the user selects
the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

Address Line 2

Title IV
Clinical
Privileges
Actions (1)

Below
Address

Text Entry The field is displayed
if the user selects
the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

UPIN identification
number?"
The field is displayed
if the user selects
the "Is the
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.

Other

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
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.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

City

Title IV
Clinical
Privileges
Actions (1)

Below
Address Line
2

Text Entry

The field is displayed
if the user selects
the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

State

Title IV
Clinical
Privileges
Actions (1)

Below City

Drop List

The field is displayed
if the user selects
the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

ZIP

Title IV
Clinical
Privileges
Actions (1)

Below State

Text Entry The field is displayed
if the user selects
the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

Description

Title IV
Clinical
Privileges
Actions (2)
Title IV
Clinical
Privileges
Actions (2)

Below an
Text Entry
action that
requires a
description
Below Basis of Text Entry
Action(s)

Period of time
number

Title IV
Clinical
Privileges
Actions (2)

Below “How
long will it
remain in
effect?”

Text Entry

Period of time
type

Title IV
Clinical

Below “How
long will it

Drop List

Description

The field is displayed
if the user selects an
action that requires
a description.
The field is displayed
if the user selects a
basis of action that
requires a
description.
The field is displayed
if the user selects “A
specific period of
time” option for
“How long will it
remain in effect?”
The field is displayed
if the user selects “A

Other
State and ZIP
entries.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

Selecting the radio
button displays the
number text entry
and type of time
period drop list.
Selecting the radio
button displays the

Label

PDF Name
Location
(step)
Privileges
remain in
Actions (2) effect?”

Response
Input Item

Visibility Trigger
specific period of
time” option for
“How long will it
remain in effect?”

Other
number text entry
and type of time
period drop list.

State Changes
Label
OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy
Select a
Profession or
Field of
Licensure

PDF Name
Title IV Clinical
Privileges Actions

Item Type
Modal

Trigger
When the user selects the link the modal is
displayed with the public burden statement content.

Title IV Clinical
Privileges Actions

Modal

Name of
Occupation

Title IV Clinical
Privileges Actions

Text Entry

License
Number

Title IV Clinical
Privileges Actions

Text Entry

Select a Basis
for Action

Title IV Clinical
Privileges Actions

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.
Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.
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?"
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.