Form 17 One-Time Query for an Individual_0915-0126

Non-visible Questions
Label

PDF Name
(step)

Location

Response Visibility
Input
Trigger
Item

Organization
Description

One-Time
Query for an
Individual
(1)

Below
Organization
Type

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

Name of
Occupation

One-Time
Query for an
Individual (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 “Name of
Occupation” if the
selected profession
or field of licensure
requires specialty
information.

Specialty

One-Time
Query for an
Individual (1)

Beside
Profession or
Field of
Licensure

Drop List

“Name of
Occupation” is
displayed in place
of “Specialty” if the
selected profession
or field of licensure
does not require
information for a
specialty.

The field is
displayed if
the user
selects a
profession or
field of
licensure that
requires
information
for specialty.

Other

Label

PDF Name
(step)

Location

Response Visibility
Input
Trigger
Item

FEIN (Federal
Employer
Identification
Number)

One-Time
Query for an
Individual (1)

Below
Text Entry
checkbox
"Does the
subject have
an FEIN, or
UPIN
identification
number?"

UPIN (Unique
Physician
Identification
Numbers)

One-Time
Query for an
Individual (1)

Entity
Selection

One-Time
Query for an
Individual (2)

Other

The field is
displayed 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.

Below FEIN
text entry

Text Entry The field is
displayed 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.

After step 1
Subject
Information

Check
boxes

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

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

State Changes
Label

PDF Name

Item Type

Trigger

OMB
Query Input - Modal
Number:
Individual
0915-0126
Expiration
Date:
mm/dd/yyyy

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

Subjects
Available

Query Input - Table
Individual

When the user selects the option to enroll from
their subject database, the summary table of the
subjects with previously saved subject
information is displayed. The user select one or
more names from the table, then select continue
to enter payment information.

Select a
Profession
or Field of
Licensure

Query Input - Modal
Individual

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

Query Input - Text Entry
Individual

The field is disabled if the user does not select a
profession or field of licensure requiring a
description.

License
Number

Query Input - Text Entry
Individual

The field is disabled if the user selects the "No/
Not sure" option for "Does the subject have a
license for your selected profession or field of
licensure?"