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pdf Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input
Item
Text
Entry
Visibility Trigger
Other
Date of Death
Exclusion or
Debarment(1)
Below "Is this
person
deceased?"
The field is
displayed if the
user selects the
"Yes" radio
button for "Is this
person deceased?"
Organization
Description
Exclusion or
Debarment(1)
Below
Text
Organization Type Entry
The field is
displayed if the
user selects an
organization type
that requires a
description.
Specialty
Exclusion or
Debarment(1)
Beside 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 selected
profession or field
of
licensure requires
specialty
information.
Description
Exclusion or
Debarment(1)
Beside 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 selected
profession or field
of licensure does
not require
information for a
specialty.
Label
PDF Name
(step)
Location
Response
Input
Item
Visibility Trigger
Other
FEIN (Federal
Employer
Identification
Number)
Exclusion or
Debarment(1)
Below checkbox
Text
"Does the subject Entry
have an FEIN, or
UPIN identification
number?"
The field is
displayed in the
individual 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)
Exclusion or
Debarment(1)
Below FEIN text
entry
Text
Entry
The field is
displayed in the
individual 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.
FDA (Federal
Food and Drug
Administration)
Exclusion or
Debarment(1)
Below checkbox
Text
"Does the subject Entry
have a FDA or CLIA
identification
number?"
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.
Label
PDF Name
(step)
Location
Response
Input
Item
Visibility Trigger
Other
CLIA (Clinical
Laboratory
Improvement
Act)
Exclusion or
Below text entry
Text
Debarment(1)) FDA (Federal Food Entry
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
Exclusion or
Debarment(1)
Below "Is the
practitioner
affiliated with a
health care
entity?" checkbox
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.
Entity Name
Exclusion or
Debarment(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
Selecting the
checkbox displays
Type of
Affiliation, Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP entries.
Country
Exclusion or
Debarment(1)
Below "Is the
practitioner
affiliated with a
health care
entity?" checkbox
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. United
States is the
default selection.
Label
PDF Name
(step)
Location
Response
Input
Item
Visibility Trigger
Other
Address
Exclusion or
Debarment(1)
Below Country
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
Exclusion or
Debarment(1)
Below Address
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
Exclusion or
Debarment(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
Selecting the
checkbox displays
Type of
Affiliation, Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP entries.
State
Exclusion or
Debarment(1)
Below City
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. .
Label
PDF Name
(step)
Location
Below State
Response
Input
Item
Visibility Trigger
Other
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.
ZIP
Exclusion or
Debarment(1)
Description
Exclusion or
Below an action
Debarment (2) that requires a
description
Text
Entry
The field is
displayed if the
user selects an
action that
requires a
description.
Description
Exclusion or
Below Basis of
Debarment (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
Exclusion or
Below “How long
Debarment (2) 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
Exclusion or
Below “How long
Debarment (2) 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
Date of Appeal
PDF Name
(step)
Location
Exclusion or
Below Is the
Debarment (2) action on appeal?
Response
Input
Item
Text
Entry
Visibility Trigger
The field is
displayed if the
user selects Yes
option for “Is the
action on appeal?”
Other
State Changes
Label
PDF Name
Item Type
Trigger
OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy
Exclusion or
Debarment
Modal
When the user selects the link the modal is displayed
with the public burden statement content.
Select a
Profession or
Field of
Licensure
Exclusion or
Debarment
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.
Name of
Occupation
Exclusion or
Debarment
Text Entry
Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.
License
Number
Exclusion or
Debarment
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
Exclusion or
Debarment
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 | Exclusion or Debarment |
| Subject | NPDB report |
| Author | Health Resources and Services Administration |
| File Modified | 2020-11-19 |
| File Created | 2020-11-18 |