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pdf Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
The field is
displayed if the user
selects Work radio
button for Type of
Address.
Other
Organization
Name
Self-Query
on an
Individual
(1)
Below Home
and Work
radio buttons
for Type of
Address
Text Entry
Organization
Type
Self-Query
on an
Individual
(1)
Below
Organization
Name text
entry
Drop list
Organization
Description
Self-Query
on an
Individual
(1)
Below
Organization
Type
Text Entry
The field is
displayed if the user
selects an
organization type
that requires a
description.
Specialty
Self-Query
on 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
“Specific Name of
Occupation” if the
selected profession
or field of
licensure requires
specialty
information.
Specific Name Self-Query
of Occupation on an
Individual
(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.
“Specific Name of
Occupation” is
displayed in place of
“Specialty” if the
selected profession
or field of licensure
does not require
information for
specialty.
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
DEA (Drug
Enforcement
Agency)
Self-Query
on an
Individual
(1)
Below
checkbox "Do
you have a
DEA, FEIN, or
UPIN
identification
number?"
Text Entry
Field is displayed if
user selects the
checkbox for "Do
you have a DEA,
FEIN, or UPIN
identification
number?"
Selecting the
checkbox displays
DEA, FEIN and UPIN
text entry fields.
FEIN (Federal
Employer
Identification
Number)
Self-Query
on an
Individual
(1)
Below DEA
text entry.
Text Entry
The field is
displayed if the user
selects the
checkbox for "Do
you have a DEA,
FEIN, or UPIN
identification
number?"
Selecting the
checkbox displays
DEA, FEIN and UPIN
text entry fields.
UPIN (Unique
Physician
Identification
Numbers)
Self-Query
on an
Individual
(1)
Below FEIN
text entry
Text Entry
The field is
displayed if the user
selects the
checkbox for "Do
you have a DEA,
FEIN, or UPIN
identification
number?"
Selecting the
checkbox displays
DEA, FEIN and UPIN
text entry fields.
Country
Self-Query
on an
Individual
(2)
Below "Same Drop List
as delivery
address" and
"A different
address"
options for
Billing Address
The field is
displayed if the user
selects the radio
button "A different
address"
Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries. United
States is the default
selection.
Address
Self-Query
on an
Individual
(2)
Below Country Text Entry
The field is
displayed if the user
selects the radio
button "A different
address"
Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
Address Line 2 Self-Query
on an
Individual
(2)
Below Address Text Entry
The field is
displayed if the user
selects the radio
button "A different
address"
Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries.
City
Self-Query
on an
Individual
(2)
Below Address Text Entry
Line 2
The field is
displayed if the user
selects the radio
button "A different
address"
Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries.
State
Self-Query
on an
Individual
(2)
Beside City
Drop List
The field is
displayed if the user
selects the radio
button "A different
address"
Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries.
ZIP
Self-Query
on an
Individual
(2)
Below State
Text Entry
The field is
displayed if the user
selects the radio
button "A different
address"
Selecting "A different
address" displays
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Label
Experian
Questions
PDF Name
(step)
Self-Query
on an
Individual
(4)
Location
Response
Input Item
After Step (3) - Radio
Review
button
Information
Visibility Trigger
Other
Question and answer
content is
determined by
Experian. User will
be shown four
questions, at least
one of which
contains financial
information. The
questions are
customized based on
the user's
information. The
user may be shown
questions other than
those pictured in the
PDF.
State Changes
Label
PDF Name
Item Type
Trigger
Place a SelfQuery Order
Self-Query on an Modal
Individual
When user starts a Self-Query, the modal is
displayed.
OMB Number:
0915-0126
Expiration Date:
mm/dd/yyyy
Self-Query on an Modal
Individual
When the user selects the link the modal is
displayed with the public burden statement
content.
Confidentiality
Statement
Self-Query on an Modal
Individual
When the user selects the Confidentiality link
the modal is displayed.
Select an
Self-Query on an Modal
Occupation or
Individual
Field of Licensure
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.
Other Name for
Occupation
Self-Query on an Text Entry
Individual
Text entry is disabled if the user does not
select a profession or field of licensure
requiring a description.
License Number
Self-Query on an Text Entry
Individual
Text entry is disabled if the user selects the
"No/ Not sure" option for "Do you have a
license for your selected profession or field of
licensure?"
Password
Requirements
Self-Query on an Info box
Individual
When the user sets focus on the "Create a
new password" text entry, the info box is
displayed. The state of each rule changes to
indicate whether or the rule is met as the user
enters their text.
Additional Functionality Changes
Label
PDF Name
(step)
Response Input
Item
Trigger
User ID
Self-Query on an Text entry
Individual (1)
If additional account functionality is available
and a User ID is required as a unique
identifier, then this field will be presented.
Mobile Phone
(Optional)
Self-Query on an Text entry
Individual (1)
If 3rd factor authentication is active, mobile
phone will be collected and used.
Question
Self-Query on an Drop list
Individual (1)
If account recovery functionality is available,
challenge questions will be presented. The
user will select a question from the list. Five
challenge questions will be presented. The
user must select different questions for each.
Answer
Self-Query on an Text entry
Individual (1)
If account recovery functionality is available,
and the challenge questions are displayed, the
user must provide an answer for each
question they selected.
Select
notification
service
Self-Query on an Checkbox
Individual (2)
When additional services are available, the
user will have an option to select the service.
Select paper
copy service
Self-Query on an Checkbox
Individual (2)
When additional services are available, the
user will have an option to select the service.
Save payment
information
Self-Query on an Checkbox
Individual (2)
When additional account functionality is
available, the user will have the option to save
their payment information to their account.
| File Type | application/pdf |
| File Title | Self-Query on an Individual |
| Subject | NPDB forms |
| Author | Health Resources and Services Administration |
| File Modified | 2020-11-19 |
| File Created | 2020-11-17 |