Attachment 10 Entities survey codebook 1-21

OMB Number: 0915-0366; Expiration date: XX/XX/202X

Da a f a e: clea

Entities Survey Codebook: Draft November 2020

ID

N

T

L

L

1

S a Da e

n me ic

S a Da e

2

EndDa e

n me ic

End Da e

3

P ge

n me ic

P ge

: 100-100

4

D a i n__in_ ec nd _

n me ic

D a i n (in ec nd )

: 1099-1623

5

Fini hed

n me ic

Fini hed

6

Rec dedDa e

n me ic

Rec ded Da e

7

Re

n eId

cha ac e

Re

9

Q3_0_GROUP_3

n me ic

In ha egi n f he
c n i
gani a i n
l ca ed? If
gani a i n e a e
in m l i le
egi n , elec all ha
a l b ank de ing
hem. - G
Ranked egi n Regi n
2: Ne
Je e , Ne Y k,
P e Ric , Vi gin
I land

1

Regi n 2: Ne Je e , Ne
Y k, P e Ric , Vi gin
I land

12

Q3_0_GROUP_7

n me ic

In ha egi n f he
c n i
gani a i n
l ca ed? If
gani a i n e a e
in m l i le
egi n , elec all ha
a l b ank de ing
hem. - G
Ranked egi n Regi n
5:
Illin i , Indiana,
Michigan, Minne a,
Ohi ,
Wi c n in

1

Regi n 5: Illin i , Indiana,
Michigan, Minne a, Ohi ,
Wi c n in

19

Q3_0_3_RANK

n me ic

In ha egi n f he
c n i
gani a i n
l ca ed? If
gani a i n e a e
in m l i le

1
2
3
4
5
6

1
2
3
4
5
6

0
1

n e ID

Fal e
T e

<

mi ed>

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

egi n , elec all ha
a l b ank de ing
hem. - Rank - Ranked
egi n - Regi n 2:
Ne
Je e , Ne Y k,
P e Ric , Vi gin
I land Rank

7
8
9
10

7
8
9
10

22

Q3_0_7_RANK

n me ic

In ha egi n f he
c n i
gani a i n
l ca ed? If
gani a i n e a e
in m l i le
egi n , elec all ha
a l b ank de ing
hem. - Rank - Ranked
egi n - Regi n 5:
Illin i , Indiana,
Michigan, Minne a,
Ohi ,
Wi c n in - Rank

1
2
3
4
5
6
7
8
9
10

1
2
3
4
5
6
7
8
9
10

28

Q4

n me ic

Which f he f ll
be cha ac e i e
gani a i n?

1
7

M
gani a i n e
ad e e ac i n
mal ac ice
a men
he NPDB ha
cc in m
gani a i n
egi n (e.g., an inde enden
h i al l ca ed in ne a ea
a h i al
em e
ing
f m a ingle a ea).
M
gani a i n e
ad e e ac i n
mal ac ice
a men
he NPDB ha
cc in m l i le egi n
(e.g., a h i al
em
l ca ed in m l i le egi n
and e
ing f m he
e ec i e egi n ).

29

Q5

n me ic

Which f he f ll ing
be de c ibe
gani a i n? Selec
ne ca eg . - Selec ed
Ch ice

1
2
4
7
8
9
10
11
12
13
14
15

H i al H i al S em
Heal h Plan
O he Heal h Ca e En i ie
(e.g., G
P ac ice,
C mm ni Heal h Cen e ,
Clinic, U gen Ca e
Amb la
Heal h Ca e
Facili
an he heal h ca e
gani a i n ha i n a
h i al)
P fe i nal S cie
Medical Mal ac ice Pa e
S a e Licen ing B a d S a e

ing

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

Ce i ca i n A h i
Fede al Licen ing Agenc
Fede al S a e P ec
(incl ding A ne Gene al)
O he S a e Agenc
O he Fede al Agenc
A h i ed Agen f NPDB
Regi e ed Heal h Ca e
En i ie
O he (Plea e E lain)
30

Q5_15_TEXT

cha ac e

Which f he f ll ing
be de c ibe
gani a i n? Selec
ne ca eg . - O he
(Plea e
E lain) - Te

32

Q7_6_TEXT

cha ac e

Which f he f ll ing
ca eg ie be
de c ibe
gani a i n? - O he
( lea e
ecif ) - Te

35

Q10_7_TEXT

cha ac e

F he
ical ea ,
h man affed bed
a e in
h i al? - D n
kn (Plea e E lain)
Te

37

Q11_8_TEXT

cha ac e

F he
ical ea ,
a
ima el h
man
a ien (incl ding
in a ien and
a ien )
d e
h i al
e e? - D n kn
(Plea e
E lain) - Te

39

Q12_10_TEXT

cha ac e

H
ld
cha ac e i e
h i al? Selec
ne f he ca eg ie
bel : - O he (Plea e
E lain) - Te

41

Q13_5_TEXT

cha ac e

H i
h i al
in ed f medical
mal ac ice? - O he
(Plea e E lain) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

43

Q14_6_TEXT

cha ac e

In
h i al, h i
named in medical
mal ac ice ca e ? O he (Plea e E lain)
- Te

48

Q15_4_TEXT

cha ac e

F
h

49

Q15_5_TEXT

cha ac e

F
h

he
ical ea ,
man heal h ca e
ac i i ne d e
h i al
ide
medical
mal ac ice in ance?
- D n kn (Plea e
E lain) - Te
he
ical ea ,
man heal h ca e
ac i i ne d e
h i al
ide
medical
mal ac ice in ance?
- O he c mmen (if
ha e an ) - Te

50

Q16_1_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

hem in he e b
ided bel . - MD
and DO
- F ll-Time
51

Q16_1_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - MD
and DO
- Pa -Time

52

Q16_1_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - MD
and DO
- C n ac
53

Q16_1_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - MD

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

and DO
- L c m enen
54

Q16_1_5

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - MD
and DO
- D n kn ( lea e
e lain)

55

Q16_2_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Den i F ll-Time
56

Q16_2_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Den i Pa -Time

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

57

Q16_2_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Den i C n ac

58

Q16_2_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Den i L c m enen
59

Q16_2_5

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Den i D n kn ( lea e
e lain)

60

Q16_3_1

cha ac e

F each f he
ca eg ie li ed bel

,

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - F ll-Time
61

Q16_3_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - Pa -Time
62

Q16_3_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - C n ac

63

Q16_3_4

cha ac e

F each f he
ca eg ie li ed bel

,

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - L c m enen
64

Q16_3_5

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - D n kn
( lea e
e lain)
65

Q16_4_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - F ll-Time

66

Q16_4_2

cha ac e

F

each f he

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - Pa -Time
67

Q16_4_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - C n ac
68

Q16_4_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - L c m enen

69

Q16_4_5

cha ac e

F each f he
ca eg ie li ed bel
h man
heal h ca e

,

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - D n kn
( lea e e lain)
70

Q16_5_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - F ll-Time
71

Q16_5_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - Pa -Time

72

Q16_5_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - C n ac
73

Q16_5_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

f

an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - L c m
enen
74

Q16_5_5

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - D n
kn ( lea e e lain)

75

Q16_6_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne - F llTime
76

Q16_6_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

f

an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne - Pa Time
77

Q16_6_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne C n ac

78

Q16_6_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne - L c m
enen
79

Q16_6_5

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
h i al?
T e a n mbe f each
ca eg . If
d n
kn , elec d n
kn
and e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

f

an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne - D n
kn ( lea e
e lain)
80

Q17

cha ac e

C mmen (if
an )

84

Q18_4_TEXT

cha ac e

H man em l ee
in
h i al a e
e n ible f hi ing
and g an ing i ilege
ac i i ne ? C mmen (if
an ): Te

ha e

ha e

85

Q394

n me ic

H
f en d e
h i al e ie he
ec d f
ac i i ne em l ed
n aff g an ed
i ilege a
facili ? - Selec ed
Ch ice

86

Q394_9_TEXT

cha ac e

H
f en d e
h i al e ie he
ec d f
ac i i ne em l ed
n aff g an ed
i ilege a
facili ? - O he (Plea e
E lain) - Te

105

Q19_22_TEXT

cha ac e

Which f he f ll ing
ce d e
h i al
ili e f hi ing
g an ing i ilege
a
ac i i ne ? (Plea e
elec all ha a l .) O he (Plea e E lain)
- Te

108

Q23

cha ac e

If
kn

elec ed 'D n
' in he e i

1
4
5
6
7
8
9

Once e e 6 m n h
Once e ea
Once e e 2 ea
Once e e 3 ea
Once e e 4 m e ea
Ong ing
O he (Plea e E lain)

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e i n, lea e
e lain:
121

Q24_12_TEXT

cha ac e

In he la 5 ea , h
man ime ha
h i al aken he
f ll ing ac i n
ega ding
ac i i ne ? (Onl
ne an e e
.) O he
(Plea e E lain) - Te

125

Q26_6_TEXT

cha ac e

D e
h i al e
a i k managemen
g am
f ed cing medical
e
? - O he (Plea e
E lain) - Te

128

Q28_4_TEXT

cha ac e

I
h i al
acc edi ed b a na i nal
acc edi a i n
gani a i n? - N
A licable
(Plea e E lain) - Te

130

Q29_18_TEXT

cha ac e

Which gani a i n ha
acc edi ed
h i al? O he (Plea e S ecif )
- Te

133

Q31_5_TEXT

cha ac e

I
h i al l ca ed
in a a e he e he
medical b a d ha a
m ne a
enal (f
he
h i al) f n
e
ing clinical
i ilege
ac i n
he a e
medical b a d? - N
A licable (Plea e
E lain) - Te

134

Q395

n me ic

Ha
h i al e e
1
been enali ed b he
4
ae
5
medical b a d f n
e
ing clinical
i ilege ac i n
he
a e medical b a d?

Ye
N
D n

Ha
h i al e e
ecei ed a a ing f

Ye
N

135

Q396

n me ic

1
4

kn

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a ien afe and
5
ali
f ca e f m he 6
Cen e f Medica e &
Medicaid Se ice
(CMS)? Selec ed Ch ice

N A licable (Plea e
E lain)
D n kn

136

Q396_5_TEXT

cha ac e

Ha
h i al e e
ecei ed a a ing f
a ien afe and
ali
f ca e f m he
Cen e f Medica e &
Medicaid Se ice
(CMS)? N A licable (Plea e
E lain) - Te

137

Q397

n me ic

Which f he f ll
a ing ha
h
ecei ed f m he
CMS?

ing
i al

1
4
5
6
7
8

One a
T
a
Th ee a
F
a
Fi e a
D n kn

138

Q398

n me ic

Ha
h i al e e
ecei ed a a ing/g ade
f
a ien afe and
ali
f ca e f m
an
gani a i n he han
he CMS? - Selec ed
Ch ice

1
4
5
6

Ye
N
N A licable (Plea e
E lain)
D n kn

139

Q398_5_TEXT

cha ac e

Ha
h i al e e
ecei ed a a ing/g ade
f
a ien afe and
ali
f ca e f m
an
gani a i n he han
he CMS? - N
A licable
(Plea e E lain) - Te

140

Q399

cha ac e

Wha i he name f he
gani a i n ha
a ed/g aded
h i al?

<

mi ed>

141

Q400

cha ac e

Which a ing/g ade did
he gani a i n gi e
h i al?

<

mi ed>

143

Q33_9_TEXT

cha ac e

Which f he f ll
be cha ac e i e

ing

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n? - O he
(Plea e S ecif ) - Te
145

Q34_5_TEXT

cha ac e

I
gani a i n
af lia ed i h a la ge
en e i e ne
k
ha
ide
em l men
c eden ialing e ice
f
ac i i ne n
behalf? - O he (Plea e
E lain) - Te

147

Q35_8_TEXT

cha ac e

H
ld
cla if he la ge
en e i e
ne
k ha
ide
gani a i n i h
em l men
c eden ialing e ice
(if
a licable)? - O he
B ine En i (Plea e
E lain) - Te

149

Q36_6_TEXT

cha ac e

D e
gani a i n
e e in a ien ,
a ien , b h? N A licable (Plea e
E lain) - Te

151

Q37_8_TEXT

cha ac e

F he
ical ea ,
a
ima el h
man
a ien d e
gani a i n e e? D n
kn (Plea e E lain)
- Te

152

Q38_1_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - MD
and DO
- F ll-Time
153

Q38_1_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ided bel
and DO
- Pa -Time
154

Q38_1_3

cha ac e

. - MD

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - MD
and DO
- C n ac

155

Q38_1_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - MD
and DO
- D n kn ( lea e
e lain)
156

Q38_2_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

hem in he e b
ided bel . Den i F ll-Time
157

Q38_2_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Den i Pa -Time

158

Q38_2_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Den i C n ac
159

Q38_2_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

hem in he e b
ided bel . Den i D n kn ( lea e
e lain)
160

Q38_3_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - F ll-Time

161

Q38_3_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - Pa -Time
162

Q38_3_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e ima e. If
an c mmen
en e
hem in he e
ided bel
Ad anced
P ac ice Regi
N e -C n
163

Q38_3_4

cha ac e

ha e
, lea e
b
.e ed
ac

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ad anced
P ac ice Regi e ed
N e - D n kn
( lea e
e lain)

164

Q38_4_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - F ll-Time
165

Q38_4_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - Pa -Time
166

Q38_4_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - C n ac

167

Q38_4_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Regi e ed
N e - D n kn
( lea e e lain)
168

Q38_5_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - F ll-Time
169

Q38_5_2

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - Pa -Time

170

Q38_5_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - C n ac
171

Q38_5_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . Ph ician
A i an - D n
kn ( lea e e lain)
172

Q38_6_1

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne - F llTime

173

Q38_6_2

cha ac e

F each f he
ca eg ie li ed bel
h man

,

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

heal h ca e
ac i i ne

e e in

gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne - Pa Time
174

Q38_6_3

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne C n ac
175

Q38_6_4

cha ac e

F each f he
ca eg ie li ed bel ,
h man
heal h ca e
ac i i ne e e in
gani a i n? T e a
n mbe f each
ca eg . If
d n kn , elec
d n kn
and
e lain
e n e. If he
ca eg
i n
a licable
gani a i n,
elec N a licable.
If
gani a i n d e
n em l an ne f
a
a ic la ca eg ,
e 0 ( e ) f ha
ca eg . If
a en
e f he e ac
n mbe
f an gi en ca eg ,
ide
be
e ima e. If
ha e
an c mmen , lea e
en e
hem in he e b
ided bel . - O he
Heal h Ca e
P ac i i ne - D n
kn ( lea e
e lain)

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

176

Q39

cha ac e

C mmen (if
an )

ha e

179

Q40_4_TEXT

cha ac e

H man em l ee
in
gani a i n
ae
e n ible f hi ing
and g an ing i ilege
ac i i ne ? - D n
kn (Plea e E lain)
Te

181

Q41_9_TEXT

cha ac e

H

f en d e
gani a i n e ie he
ec d f ac i i ne
em l ed n aff
ha
ha e been g an ed
i ilege a
facili ? O he (Plea e E lain)
- Te

200

Q42_22_TEXT

cha ac e

Which f he f ll ing
ce d e
gani a i n ili e f
hi ing g an ing
i ilege
a - O he
(Plea e E lain) - Te

203

Q46

cha ac e

If
elec ed 'D n
kn ' in he e i
e i n, lea e
e lain:

207

Q48_6_TEXT

cha ac e

D e
gani a i n
e a i k managemen
g am f ed cing
medical e
? - O he
(Plea e E lain) - Te

210

Q50_6_TEXT

cha ac e

H

212

Q51_6_TEXT

cha ac e

In
gani a i n,
h i named in
medical
mal ac ice ca e ? O he (Plea e E lain)
- Te

i
gani a i n in ed
f medical
mal ac ice? - O he
(Plea e E lain) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

215

Q52_4_TEXT

cha ac e

F
h

he
ical ea ,
man heal h ca e
ac i i ne d e
gani a i n
ide
medical mal ac ice
in ance? - D n
kn
(Plea e E lain) - Te

216

Q52_5_TEXT

cha ac e

F
h

217

Q53

cha ac e

O he c mmen ab
he e i
e i n
(if
ha e an )

219

Q54_5_TEXT

cha ac e

I
gani a i n
acc edi ed b a na i nal
acc edi a i n
gani a i n? - N
A licable
(Plea e E lain) - Te

221

Q55_18_TEXT

cha ac e

Which gani a i n ha
acc edi ed
gani a i n? - O he
(Plea e S ecif ) - Te

223

Q59

n me ic

F he
ical ea ,
h man a lica i n
f
membe hi d e
fe i nal cie
ecei e?
- Selec ed Ch ice

224

Q59_1_TEXT

n me ic

F he
ical ea ,
h man a lica i n
f
membe hi d e
fe i nal cie
ecei e?
- T e a n mbe : - Te

225

Q59_4_TEXT

cha ac e

F he
ical ea ,
h man a lica i n
f
membe hi d e
fe i nal cie

he
ical ea ,
man heal h ca e
ac i i ne d e
gani a i n
ide
medical mal ac ice
in ance? - N
a licable
(Plea e E lain) - Te

1
4

T e a n mbe :
D n kn (Plea e E lain)

: 1-1

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ecei e?
- D n kn (Plea e
E lain) - Te
226

Q61

n me ic

F he
ical ea ,
h man membe hi
a lica i n d e
fe i nal cie
a
e? - Selec ed
Ch ice

227

Q61_1_TEXT

n me ic

F he
ical ea ,
h man membe hi
a lica i n d e
fe i nal cie
a
e? - T e a
n mbe : - Te

228

Q61_4_TEXT

cha ac e

F he
ical ea ,
h man membe hi
a lica i n d e
fe i nal cie
a
e? - D n
kn (Plea e E lain)
- Te

229

Q62

n me ic

F he
ical ea ,
h man membe
bel ng
fe i nal
cie ? - Selec ed
Ch ice

230

Q62_1_TEXT

n me ic

F he
ical ea ,
h man membe
bel ng
fe i nal
cie ? - T e a
n mbe : - Te

231

Q62_4_TEXT

cha ac e

F he
ical ea ,
h man membe
bel ng
fe i nal
cie ? - D n kn
(Plea e
E lain) - Te

232

Q63

n me ic

H
in

man indi id al
fe i nal

cie
a e e n ible f
g an ing membe hi
ac i i ne ? Selec ed Ch ice

1
4

T e a n mbe :
D n kn (Plea e E lain)

: 1-1

1
4

T e a n mbe :
D n kn (Plea e E lain)

: 1-1

1
4

T e a n mbe :
D n kn (Plea e E lain)

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

233

Q63_1_TEXT

n me ic

H
in

man indi id al
fe i nal

: 1-1

cie
a e e n ible f
g an ing membe hi
ac i i ne ? - T e a
n mbe : - Te
234

Q63_4_TEXT

cha ac e

H
in

man indi id al
fe i nal

cie
a e e n ible f
g an ing membe hi
ac i i ne ? - D n
kn (Plea e E lain)
Te
235

Q64

n me ic

H

f en d e
gani a i n e ie he
ec d f ac i i ne
ha ha e been g an ed
membe hi in
fe i nal cie ? Selec ed Ch ice

236

Q64_10_TEXT

cha ac e

H

240

Q65_8

n me ic

Which f he f ll ing
ce d e
fe i nal cie
ili e f g an ing
membe hi
a
ac i i ne ? (Plea e
elec all
ha a l .) - Selec ed
Ch ice Licen ing
b a d( )
in
ae

255

Q65_22_TEXT

cha ac e

Which f he f ll ing
ce d e
fe i nal cie
ili e f g an ing
membe hi
a

1
4
5
6
7
8
9
10

Once e e 6 m n h
Once e ea
Once e e 2 ea
Once e e 3 ea
Once e e 4 m e ea
Ong ing
Rec d a e ne e
inel
e ie ed af e membe hi i
g an ed.
O he (Plea e E lain)

1

Licen ing b a d( ) in
ae

f en d e
gani a i n e ie he
ec d f ac i i ne
ha ha e been g an ed
membe hi in
fe i nal cie ? O he
(Plea e E lain) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ac i i ne ? (Plea e
elec all
ha a l .) - O he
(Plea e E lain) - Te
256

Q66

n me ic

Ha
fe i nal
cie e e aken an
NPDB
e
able ac i n( )?

1
4

Ye
N

257

Q67

n me ic

In he la 5 ea , h
man ime d e
fe i nal cie
ake
fe i nal
e ie
ac i n ega ding
ac i i ne ?

1
2
3
4
5
6
7
8
9
10
11
12
13

0
1
2
3
4
5
6
7
8
9
10
m e han 10
D n kn

258

Q68

cha ac e

If 'D n kn ' in
e i
e i n, hen
lea e
e lain:

259

Q69_1

n me ic

In he la 5 ea , h
man ime d e
fe i nal cie
ake he f ll ing
ac i n
h gh a
fe i nal
e ie
ce
ega ding
ac i i ne ? (Onl
ne an e e
)Re ca i n f
P fe i nal S cie
Membe hi

1
2
3
4
5
6
7
8
9
10
11
12

1
2
3
4
5
6
7
8
9
10
m e han 10
D n kn

260

Q69_2

n me ic

In he la 5 ea , h
man ime d e
fe i nal cie
ake he f ll ing
ac i n
h gh a
fe i nal
e ie
ce
ega ding
ac i i ne ? (Onl
ne an e e
)S en i n f

1
2
3
4
5
6
7
8
9
10
11
12

1
2
3
4
5
6
7
8
9
10
m e han 10
D n kn

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

P fe i nal S cie
Membe hi
261

Q69_3

n me ic

In he la 5 ea , h
man ime d e
fe i nal cie
ake he f ll ing
ac i n
h gh a
fe i nal
e ie
ce
ega ding
ac i i ne ? (Onl
ne an e e
)Di ci lina P ba i n
Affec ing Membe hi
Righ
P i ilege

1
2
3
4
5
6
7
8
9
10
11
12

1
2
3
4
5
6
7
8
9
10
m e han 10
D n kn

262

Q69_4

n me ic

In he la 5 ea , h
man ime d e
fe i nal cie
ake he f ll ing
ac i n
h gh a
fe i nal
e ie
ce
ega ding
ac i i ne ? (Onl
ne an e e
)O he
Re ic i n/Limi a i n
n P fe i nal S cie
Membe hi (S ecif )

1
2
3
4
5
6
7
8
9
10
11
12

1
2
3
4
5
6
7
8
9
10
m e han 10
D n kn

263

Q69_4_TEXT

cha ac e

In he la 5 ea , h
man ime d e
fe i nal cie
ake he f ll ing
ac i n
h gh a
fe i nal
e ie
ce
ega ding
ac i i ne ? (Onl
ne an e e
)O he
Re ic i n/Limi a i n
n P fe i nal S cie
Membe hi (S ecif )
- Te

264

Q69_5

n me ic

In he la 5 ea , h
man ime d e
fe i nal cie
ake he f ll ing
ac i n
h gh a
fe i nal

1
2
3
4
5
6

1
2
3
4
5
6

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e ie
ce
ega ding
ac i i ne ? (Onl
ne an e e
)Denial
f P fe i nal S cie
Membe hi
(S b e en )
267

Q71_4_TEXT

cha ac e

F he
ical ea ,
h man a lica i n
(ne
and ene al ) f
licen e
ce i ca i n d e
gani a i n
ecei e? - D n kn
(Plea e
E lain) - Te

270

Q72_4_TEXT

cha ac e

F he
ical ea ,
h man a lica i n
(ne
and ene al ) d e
gani a i n
a
ef
licen e
ce i ca i n? - D n
kn (Plea e
E lain) - Te

273

Q73_4_TEXT

cha ac e

H man
al aff
membe
i hin
gani a i n a e
e n ible f
licen ing
ce if ing
ac i i ne ? - D n
kn (Plea e
E lain) - Te

275

Q74_9_TEXT

cha ac e

H

294

Q75_22_TEXT

cha ac e

Which f he f ll ing
ce d e
gani a i n ili e f
g an ing licen e
ce i ca i n a

f en d e
gani a i n e ie he
ec d f ac i i ne
f
hich
gani a i n ha
g an ed licen e
ce i ca i n? - O he
(Plea e E lain) - Te

7
8
9
10
11
12

7
8
9
10
m e han 10
D n kn

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ac i i ne ? (Plea e
elec
all ha a l .) - O he
(Plea e E lain) - Te
313

Q76_19_TEXT

cha ac e

Wha
e f ad e e
licen e
ce i ca i n
ac i n d e
gani a i n ake
ega ding
ac i i ne ? (Selec
all ha a l .) P e c i i e/Di en ing
A h i Ac i n N
Cla i ed (Plea e
S ecif ) - Te

314

Q76_20_TEXT

cha ac e

Wha
e f ad e e
licen e
ce i ca i n
ac i n d e
gani a i n ake
ega ding
ac i i ne ? (Selec
all ha a l .) P blicl
A ailable Nega i e
Ac i n Finding
(Plea e
S ecif ) - Te

315

Q76_21_TEXT

cha ac e

Wha
e f ad e e
licen e
ce i ca i n
ac i n d e
gani a i n ake
ega ding
ac i i ne ? (Selec
all ha a l .) - O he
Licen e
Ce i ca i n Ac i n
N Cla i ed
(Plea e S ecif ) - Te

317

Q77_9_TEXT

cha ac e

F
h

he
ical ea ,
man ime d e

gani a i n ake
di ci lina ac i n
ega ding
ac i i ne ? - D n
kn (Plea e E lain)
Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

322

Q81_6_TEXT

cha ac e

D e
gani a i n
ecei e clinical
i ilege
ac i n e
f m he
NPDB e
f
a ding
e ice? - O he (Plea e
E lain) - Te

325

Q83_6_TEXT

cha ac e

D e
ae
medical b a d ecei e
medical
mal ac ice a men
e
f m he
NPDB
e
ing f
a ding
e ice? - O he (Plea e
E lain) - Te

327

Q401

n me ic

D e
ae
1
medical b a d ha e a
4
m ne a
5
enal f h i al
f n e
ing
clinical
i ilege ac i n
he
a e medical b a d? Selec ed Ch ice

328

Q401_5_TEXT

cha ac e

D e
ae
medical b a d ha e a
m ne a
enal f h i al
f n e
ing
clinical
i ilege ac i n
he
a e medical b a d? N A licable (Plea e
E lain) - Te

329

Q402

cha ac e

Plea e
ide he
de ail f he m ne a
enal .

332

Q86_4_TEXT

cha ac e

F
h

he
ical ea ,
man ca e d e

f ce
ec e? - D
n kn (Plea e
E lain) Te
335

Q87_4_TEXT

cha ac e

F
h

he
ical ea ,
man ca e d e

Ye
N
N A licable (Plea e
E lain)

<

mi ed>

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

f ce e le? - D n
kn (Plea e E lain)
Te
338

Q88_4_TEXT

cha ac e

F he
ical ea ,
h man heal h ca e
ela ed
ca e ha a e
en iall e
able
he NPDB
d e
f ce
ec e? - D n
kn (Plea e
E lain) - Te

341

Q89_4_TEXT

cha ac e

F he
ical ea ,
h man heal h ca e
ela ed
ca e in
f ce ha
ae
en iall
e
able
he NPDB
a e e led? - D n
kn
(Plea e E lain) - Te

344

Q90_4_TEXT

cha ac e

F he
ical ea ,
a
ima el h
man f
he heal h ca e ela ed
ca e in
f ce ha
ae
en iall
e
able
he NPDB
e l in a
c n ic i n? - D n
kn (Plea e E lain)
- Te

347

Q91_4_TEXT

cha ac e

H man
al aff
membe
i hin
f ce
ca e
k? - D
n kn (Plea e
E lain) Te

349

Q92_4_TEXT

cha ac e

Wh i e n ible f
e
ing
he NPDB?
O he Fede al Agenc
(Plea e S ecif ) - Te

350

Q92_5_TEXT

cha ac e

Wh i e
e
ing
-

n ible f
he NPDB?

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

O he S a e Agenc
(Plea e S ecif ) - Te
351

Q92_6_TEXT

cha ac e

Wh i e n ible f
e
ing
he NPDB?
O he (Plea e E lain)
- Te

353

Q93_6_TEXT

cha ac e

D e
f ce e
an heal h ca e ela ed
ca e
he NPDB? Re
a diffe en
Fede al
agenc (Plea e
S ecif ) - Te

354

Q93_7_TEXT

cha ac e

D e
f ce e
an heal h ca e ela ed
ca e
he NPDB? Re
a diffe en
Sae
agenc (Plea e
S ecif ) - Te

357

Q96

n me ic

Ha e
e e
e ied
he NPDB n behalf f

1
4
5

Ye
N
O he (Plea e e lain)

1
4
5

Ye
N
O he (Plea e e lain)

gani a i n ( i h
ing an a h i ed
agen )?
- Selec ed Ch ice
358

Q96_5_TEXT

cha ac e

Ha e
e e
e ied
he NPDB n behalf f
gani a i n ( i h
ing an a h i ed
agen )?
- O he (Plea e e lain)
- Te

359

Q97

n me ic

Ha
gani a i n
e e
e ied he NPDB
( ih
an a h i ed
agen )? - Selec ed
Ch ice

360

Q97_5_TEXT

cha ac e

Ha
gani a i n
e e
e ied he NPDB
( ih
an a h i ed
agen )? - O he (Plea e
e lain) - Te

361

Q98_1

cha ac e

A

ha e n
e ied he NPDB, b

<

mi ed>

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi
e ie
he
NPDB
ha he can an e
he e ela ed
e
e i n . - Fi name:
362

Q98_4

cha ac e

A

ha e n
e ied he NPDB, b

<

mi ed>

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi
e ie
he
NPDB
ha he can an e
he e ela ed
e
e i n . - La name:
363

Q98_5

n me ic

A

ha e n
e ied he NPDB, b

: 98403842-98403842

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi
e ie
he
NPDB
ha he can an e
he e ela ed
e
e i n . - Tele h ne
n mbe :
364

Q98_6

cha ac e

A

ha e n
e ied he NPDB, b

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in

<

mi ed>

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n h
bmi
e ie
he
NPDB
ha he can an e
he e ela ed
e
e i n . - Email
add e :
366

Q100

n me ic

D e
gani a i n
c n ac i h an
a h i ed
agen
e he
NPDB? - Selec ed
Ch ice

367

Q100_5_TEXT

cha ac e

D e
gani a i n
c n ac i h an
a h i ed
agen
e he
NPDB? - O he (Plea e
E lain)
- Te

368

Q102

n me ic

Wh d e
gani a i n e an
a h i ed agen
e he NPDB?
(Plea e elec all ha
a l .)
- Selec ed Ch ice

369

Q102_8_TEXT

cha ac e

Wh d e
gani a i n e an
a h i ed agen
e he NPDB?
(Plea e elec all ha
a l .)
- O he (Plea e
E lain) - Te

370

Q103

n me ic

A e he e
e

ne f
en di ec l

1
4
5

Ye
N
O he (Plea e E lain)

1
4
5
6
7
8

C effec i ene
N en gh aff ime
a ailable
Highe
ali e l
C
a e manda e
NPDB
em
c m le
O he (Plea e E lain)

1
4

Sen di ec l
m
gani a i n
Sen
he agen

1
4
5
6

T a i f legal
eg la
e i emen
T a i f e i emen f
acc edi a i n gani a i n( )
T a i f in e nal
e i emen f m
gani a i n( )
O he (Plea e E lain)

gani a i n
he agen ?
371

Q105

n me ic

Wh d e
gani a i n e
NPDB? (Selec
all ha a l .) Selec ed Ch ice

he

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

372

Q105_6_TEXT

cha ac e

Wh d e
gani a i n e he
NPDB? (Selec
all ha a l .) - O he
(Plea e E lain) - Te

390

Q112_7_TEXT

cha ac e

U ing he cale
ided, lea e a e
e e ience ega ding
each f he f ll ing
a ec
f e ing he NPDB.
- O he (Plea e
E lain) Te

395

Q113_6_TEXT

cha ac e

H

d e
gani a i n b ain
NPDB inf ma i n
ab
heal h ca e
ac i i ne a lican ?
(Selec
all ha a l .) - O he
(Plea e E lain) - Te

396

Q114

cha ac e

Wha a e
gani a i n ea n
f n
ing
c n in
e ?

397

Q115

cha ac e

Wha can he NPDB d
facili a e he e f
c n in
e f
gani a i n?

400

Q117_1_TEXT

cha ac e

When d
e f
ac i i ne al ead n
aff? Selec all ha a e
a licable. - On a
eg la ched le,
ecif in e al: e e
_____m n h - Te

412

Q121_1_TEXT

cha ac e

Sh ld an change be
made
he NPDB
li f
e ne f
e f
e ? - Ye , addi i nal
e n e h ld be
added ( lea e ecif ) Te

413

Q121_4_TEXT

cha ac e

Sh ld an change be
made
he NPDB
li f

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e

ne f
e f
e ? - Ye , e i ing
e n e h ld be eded ( lea e ecif )
Te
414

Q121_5_TEXT

cha ac e

Sh ld an change be
made
he NPDB
li f
e ne f
e f
e ? - N change
ae
needed ( lea e
elab a e) - Te

416

Q122_1_TEXT

cha ac e

We a e in e e ed in
lea ning ab
he
a e age
ime i ake
gani a i n
c m le e a
ne- ime e . Plea e
ide e ima ed ime
(in
min e ) f he
f ll ing a ec f
he
e
ing
ce : Min e
en
c llec ing
inf ma i n ab
he
e - Te

417

Q122_4_TEXT

cha ac e

We a e in e e ed in
lea ning ab
he
a e age
ime i ake
gani a i n
c m le e a
ne- ime e . Plea e
ide e ima ed ime
(in
min e ) f he
f ll ing a ec f
he
e
ing
ce : Min e
en
c nd c ing he
e
n he NPDB
em - Te

419

Q123_1_TEXT

cha ac e

We a e in e e ed in
lea ning ab
he
a e age

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ime i ake
gani a i n
c m le e a
c n in
e .
Plea e
ide
e ima ed ime
(in min e ) f he
f ll ing a ec f
he
e
ing
ce : Min e
en
c llec ing
inf ma i n ab
he
e - Te
420

Q123_4_TEXT

cha ac e

We a e in e e ed in
lea ning ab
he
a e age
ime i ake
gani a i n
c m le e a
c n in
e .
Plea e
ide
e ima ed ime
(in min e ) f he
f ll ing a ec f
he
e
ing
ce : Min e
en
c nd c ing he
e
n he NPDB
em - Te

423

Q125_7_TEXT

cha ac e

The la ime hi
ha ened, ha ac i n
did
ake? (Selec all ha
a l .) - O he ( lea e
e lain) - Te

424

Q126

cha ac e

If he e i an hing el e
ab
e
e e ience ha
ld like
ha e
ih ,
lea e en e i he e:

425

Q128

n me ic

H
ld
de c ibe he c
f
NPDB ne- ime
e ?

1
4
5
6
7

Ve
E
Fai
Ine
Ve

426

Q129

n me ic

H
ld
de c ibe he c

1
4

Ve E en i e
E en i e

f

E en i e
en i e
C
en i e
Ine en i e

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

NPDB c n in
e ?

5
6
7

Fai C
Ine en i e
Ve Ine en i e

427

Q130_1

n me ic

Plea e a e
gani a i n le el f
a i fac i n f each f
he f ll ing i em .
(Onl ne an e e
.) - One-Time
Q e

1
2
3
4
5
6

Ve Sa i ed
Sa i ed
Nei he Sa i ed N
Di a i ed
Di a i ed
Ve
Di a i ed

428

Q130_2

n me ic

Plea e a e
gani a i n le el f
a i fac i n f each f
he f ll ing i em .
(Onl ne an e e
.) - C n in
Q e

1
2
3
4
5
6

Ve Sa i ed
Sa i ed
Nei he Sa i ed N
Di a i ed
Di a i ed
Ve
Di a i ed

429

Q130_3

n me ic

Plea e a e
gani a i n le el f
a i fac i n f each f
he f ll ing i em .
(Onl ne an e e
.) - P ac i i ne
(S bjec ) Da aba e

1
2
3
4
5
6

Ve Sa i ed
Sa i ed
Nei he Sa i ed N
Di a i ed
Di a i ed
Ve
Di a i ed

430

Q130_4

n me ic

Plea e a e
gani a i n le el f
a i fac i n f each f
he f ll ing i em .
(Onl ne an e e
.) - Re-Q e
f
P e i l Sa ed
P ac i i ne

1
2
3
4
5
6

Ve Sa i ed
Sa i ed
Nei he Sa i ed N
Di a i ed
Di a i ed
Ve
Di a i ed

431

Q131

n me ic

H

d e he ea e f
e ing he NPDB
c m ae
he ea e f eeking
inf ma i n f m he
ce
e?

1
4
5
6
7

NPDB i m ch m e dif c l
NPDB i
me ha dif c l
NPDB i a ea a he
ce
NPDB i
me ha ea ie
NPDB i m ch ea ie

432

Q132

n me ic

H

d e he c
f
e ing he NPDB
c m ae
he c
f b aining
inf ma i n f m he
ce
e?

1
4
5
6
7

NPDB i m ch m e
e en i e
NPDB i
me ha e en i e
NPDB c
ab
he ame
a he
ce
NPDB i
me ha chea e
NPDB i m ch chea e

433

Q134_1

n me ic

Wha d
hink a e
heal h ca e
gani a i n

1
2
3

Ne al
Sligh l Nega i e
S me ha Nega i e

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - Medical
Mal ac ice Pa men

4
5

M de a el Nega i e
E emel Nega i e

434

Q134_2

n me ic

Wha d
hink a e
heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - S a e
Licen e Ac i n

1
2
3
4
5

Ne al
Sligh l Nega i e
S me ha Nega i e
M de a el Nega i e
E emel Nega i e

435

Q134_3

n me ic

Wha d
hink a e
heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - Clinical
P i ilege / Panel
Membe hi
Ac i n

1
2
3
4
5

Ne al
Sligh l Nega i e
S me ha Nega i e
M de a el Nega i e
E emel Nega i e

436

Q134_4

n me ic

Wha d
hink a e
heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - Heal h Plan
O he Adj dica ed
Ac i n
(e.g., c n ac
e mina i n)

1
2
3
4
5

Ne al
Sligh l Nega i e
S me ha Nega i e
M de a el Nega i e
E emel Nega i e

437

Q134_5

n me ic

Wha d

1

Ne

hink a e

al

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - P fe i nal
S cie Membe hi
Ac i n

2
3
4
5

Sligh l Nega i e
S me ha Nega i e
M de a el Nega i e
E emel Nega i e

439

Q134_7

n me ic

Wha d
hink a e
heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - G e nmen
Admini a i e Ac i n

1
2
3
4
5

Ne al
Sligh l Nega i e
S me ha Nega i e
M de a el Nega i e
E emel Nega i e

440

Q134_8

n me ic

Wha d
hink a e
heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - Fede al
S a e E cl i n
Deba men

1
2
3
4
5

Ne al
Sligh l Nega i e
S me ha Nega i e
M de a el Nega i e
E emel Nega i e

442

Q134_10

n me ic

Wha d
hink a e
heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - J dgmen
C n ic i n

1
2
3
4
5

Ne al
Sligh l Nega i e
S me ha Nega i e
M de a el Nega i e
E emel Nega i e

443

Q134_11

n me ic

Wha d
heal h ca e

1
2

Ne al
Sligh l Nega i e

hink a e

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - O he (Plea e
E lain)

3
4
5

S me ha Nega i e
M de a el Nega i e
E emel Nega i e

444

Q134_11_TEXT

cha ac e

Wha d
hink a e
heal h ca e
gani a i n
e ce i n f heal h
ca e ac i i ne
ih
an
f he f ll ing e
in he NPDB? (Plea e
elec f m he a ing
cale f each f he
i em .) - O he (Plea e
E lain) - Te

<

mi ed>

448

Q135_4

n me ic

H
f en d e
ecei ing he f ll ing
kind f
e
f m he NPDB
im ac n heal h ca e
ac i i ne abili
b ain ce i ca i n,
licen ing,
c eden ialing, clinical
i ilege ,
em l men . (Plea e
elec f m he a ing
cale
f each f he i em .) Heal h Plan O he
Adj dica ed Ac i n
(e.g., c n ac
e mina i n)

1
4
5
6
7
8
9
13

All he Time
M
f he Time
M e han Half he Time
Ab
Half he Time
Le han Half he Time
Ra el
Ne e
O he

451

Q135_7

n me ic

H
f en d e
ecei ing he f ll ing
kind f
e
f m he NPDB
im ac n heal h ca e
ac i i ne abili
b ain ce i ca i n,
licen ing,
c eden ialing, clinical
i ilege ,
em l men . (Plea e
elec f m he a ing

1
4
5
6
7
8
9
13

All he Time
M
f he Time
M e han Half he Time
Ab
Half he Time
Le han Half he Time
Ra el
Ne e
O he

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

cale
f each f he i em .) G e nmen
Admini a i e Ac i n
456

Q135_11_TEXT

cha ac e

H
f en d e
ecei ing he f ll ing
kind f
e
f m he NPDB
im ac n heal h ca e
ac i i ne abili
b ain ce i ca i n,
licen ing,
c eden ialing, clinical
i ilege ,
em l men . (Plea e
elec f m he a ing
cale
f each f he i em .) O he (Plea e E lain)
Te

457

Q174

cha ac e

If elec ed "N
A licable" "O he ",
lea e
e lain:

458

Q136

n me ic

H d e ha ing a
medical mal ac ice
a men
e
in he NPDB
im ac a heal h ca e
ac i i ne medical
liabili in ance?

482

Q139_11_TEXT

cha ac e

H

494

Q140_11_TEXT

cha ac e

H d e ha ing he
f ll ing kind f
e
in
he NPDB im ac n
heal h ca e
ac i i ne
abili
b ain
ce i ca i n, licen ing,
c eden ialing, clinical

likel i i ha
gani a i n ill
ejec an a lica i n
i h an f he
f ll ing
e
in he NPDB? O he (Plea e E lain)
Te

1
4
5

N im ac
Nega i e im ac (inc ea ed
emi m
ha d ge
in ance)
D n kn

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

i ilege ,
em l men
ab e and be nd he
im ac f he iginal
ac i n
ha e l ed in he
e
? Tha i , ha
kind f
an im ac an NPDB
e
ha , n he
ac i n
i elf? - O he (Plea e
E lain) - Te
514

Q145_19_TEXT

cha ac e

Wha
e f
inf ma i n did
gani a i n
e e ecei e a a e l
f c nd c ing an
NPDB
e ( ega dle
f
ne- ime c n in
e )? (Plea e elec
all ha a l .) - O he
(Plea e E lain) - Te

516

Q146_11_TEXT

cha ac e

H

534

Q147_19_TEXT

cha ac e

Wha kind f e
ha
gani a i n
ecei ed hich
c n ained ne
inf ma i n ha i
had n
b ained
h gh he
ce
(e.g.,
em l men
a lica i n f
ac i i ne , e
e n e f m he
FSMB, e n e
e e f
inf ma i n f m
e i
k ie ,

f en d
e e l f m he
NPDB
ide
i h ne
inf ma i n ab
ac i i ne ha
did n
b ain h gh
he
ce ,
incl ding he
ac i i ne
a lica i n? - O he
(Plea e E lain) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e c.)?
(Plea e elec all ha
a l .) - O he (Plea e
E lain) - Te
543

Q148_10_TEXT

cha ac e

Wha
e f ac i n
d e
gani a i n
ake
hen a e e n e
c n ain ad e e ac i n
e
, j dgmen
c n ic i n e
,
medical mal ac ice
a men e
n
ac i i ne a
facili ? (Plea e elec
all
ha a l .) - O he
(Plea e E lain) - Te

557

Q149_15_TEXT

cha ac e

Which f he f ll ing
deci i n a e affec ed
b
he inf ma i n
ided b he
NPDB? (Plea e
elec all ha a l .) O he (Plea e E lain)
Te

559

Q150_5_TEXT

cha ac e

W ld
deci i n
( elec ed in he
e i
e i n) ega ding
ac i i ne ( ) ha e
been
diffe en if
had n
ecei ed he NPDB
e n e? - O he
(Plea e E lain) - Te

578

Q152_17_TEXT

cha ac e

F each
e f e
li ed bel , lea e a e
i effec n
gani a i n deci i n
ffe em l men ,
c eden ialing,
licen ing,
ce i ca i n,
g an ing f clinical
i ilege
if he ac i i ne had
ch a e
in he

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

NPDB.
(Onl ne an e e
.) - O he (Plea e
E lain) - Te
580

Q153_11_TEXT

cha ac e

H

f en d e
gani a i n c n ac
he
iginal e
e f
addi i nal inf ma i n
hen
i ecei e e
e l ing f m e ing
he
NPDB? - O he (Plea e
E lain) - Te

582

Q154_11_TEXT

cha ac e

H
f en d e
inf ma i n f m he
NPDB lead
f he in e iga i n
in addi i nal
ce
f
inf ma i n? - O he
(Plea e E lain) - Te

589

Q157_6_TEXT

cha ac e

The la ime hi
ha ened, ha ac i n
did
ake? (Selec all ha
a l .) - O he ( lea e
e lain) - Te

595

Q159_6_TEXT

cha ac e

Wha d e
gani a i n d in he
e en f a
n n- e n e a
e (e.g.,
ee
e ec ing
a e
b he e a
n di cl
e f an
e
)? (Selec all ha
a l .) - O he ( lea e
e lain) - Te

598

Q163_1

cha ac e

A
e
b

ha e n
ed
he NPDB,

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi e
he

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

NPDB
ha he can an e
he e
ela ed
e
e i n . - Fi name:
599

Q163_5

cha ac e

A
e
b

ha e n
ed
he NPDB,

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi e
he
NPDB
ha he can an e
he e
ela ed
e
e i n . - La name:
601

Q163_7

cha ac e

A
e
b

ha e n
ed
he NPDB,

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi e
he
NPDB
ha he can an e
he e
ela ed
e
e i n . - Email
add e :
613

Q170_8_TEXT

cha ac e

Wh d e
gani a i n e an
a h i ed agen
e
ad e e
ac i n
he NPDB?
(Plea e
elec all ha a l .) O he (Plea e E lain)
Te

633

Q180_8_TEXT

cha ac e

U ing he cale
ided, lea e a e
e e ience ega ding
each f he f ll ing

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a ec
f e
ing ad e e
ac i n
he NPDB. O he
(Plea e E lain) - Te
635

Q182

cha ac e

E lain he ea n f
ch ice ab
he
ime
ela ed f m hen an
ad e e ac i n cc
he
da e
le a e
he NPDB.

638

Q183_5

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
ad e e ac i n e
.
Plea e
ide
e ima ed
ime (in min e ) f
he f ll ing a ec
f he
e
ing
ce : - N
a licable ( lea e
e lain)

640

Q185

n me ic

Sh ld an change be
made
he li f
Ad e e
Ac i n Cla i ca i n
e n e ? - Selec ed
Ch ice

641

Q185_1_TEXT

cha ac e

Sh ld an change be
made
he li f
Ad e e
Ac i n Cla i ca i n
e n e ? - Ye ,
addi i nal
e n e h ld be
added ( lea e ecif ) Te

642

Q185_4_TEXT

cha ac e

Sh ld an change be
made
he li f
Ad e e
Ac i n Cla i ca i n
e n e ? - Ye ,
e i ing
e n e h ld be

1
4
5

Ye , addi i nal e n e
h ld be added ( lea e
ecif )
Ye , e i ing e n e h ld
be changed ( lea e ecif )
N change a e needed
( lea e elab a e)

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

changed ( lea e
ecif ) Te
643

Q185_5_TEXT

cha ac e

Sh ld an change be
made
he li f
Ad e e
Ac i n Cla i ca i n
e n e ?-N
change a e
needed ( lea e
elab a e) - Te

653

Q189_1_TEXT

cha ac e

Sh ld an change be
made
he li f
Ba i
f Ac i n e n e ? Ye , addi i nal
e ne
h ld be added
( lea e ecif ) - Te

654

Q189_4_TEXT

cha ac e

Sh ld an change be
made
he li f
Ba i
f Ac i n e n e ? Ye , e i ing e n e
h ld be changed
( lea e ecif ) - Te

655

Q189_5_TEXT

cha ac e

Sh ld an change be
made
he li f
Ba i
f Ac i n e n e ? Ye , e n e h ld
be
ail ed acc ding
he e
ed
fe i n
( lea e ecif ) - Te

656

Q189_7_TEXT

cha ac e

Sh ld an change be
made
he li f
Ba i
f Ac i n e n e ? N change a e needed
( lea e elab a e) Te

657

Q190

cha ac e

If
ha e an
c mmen ab
inf ma i n e
he NPDB f ad
ac i n , lea e
hem he e:

669

Q193_8_TEXT

cha ac e

The la

ime hi

he
he
ed
e e
ide

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ha ened, ha ac i n
did
ake? (Selec all ha
a l .) - O he ( lea e
e lain) - Te
671

Q194_6_TEXT

cha ac e

When bmi ing a
clinical i ilege
ac i n
e
a
fe i nal
cie ac i n e
he NPDB, d e
gani a i n e he
NPDB
e
f
a ding
e ice in de
end
an
elec nic e
he
a
ia e a e
a h i ? - O he
(Plea e E lain) - Te

676

Q200

cha ac e

Plea e e lain h
he
NPDB e
ing
e i emen
im ac he di ci lina
ac i n
gani a i n
ake ega ding
ac i i ne .

679

Q202_6_TEXT

cha ac e

Ha
gani a i n
e e been named in a
ci il
la
i ac i n b a
ac i i ne ega ding
e
ing
he NPDB?
- O he (Plea e
E lain) Te

701

Q207

cha ac e

H can he NPDB be
m e ef l
?

716

Q209_14_TEXT

cha ac e

H

731

Q210_14_TEXT

cha ac e

Plea e a e
gani a i n le el f

f e en l d e
gani a i n e
each f
he f ll ing NPDB
e
ce ? (Onl ne
an e e
.) - O he (Plea e
E lain) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a i fac i n i h each
f he f ll ing NPDB
e
ce . (Onl ne
an e e
.) O he
(Plea e E lain) - Te
733

Q212

cha ac e

Wha NPDB c
me
e ice h
ld be
f cien f
gani a i n? (Plea e
indica e
he ime ne in
e n e.)

745

Q213_11_TEXT

cha ac e

Wha i
le el f
a i fac i n i h he
a i ance
ha e
ecei ed f m he
NPDB
C
me Se ice
Cen e ega ding each
f he
f ll ing? - O he
( ecif ) - Te

746

Q214

cha ac e

Wha i he
ical ai
ime hen
call he
C
me Se ice
Cen e ?

748

Q215_11_TEXT

cha ac e

When
c n ac he
C
me Se ice
Cen e , h
f en a e he c
me
e ice e nnel able
an e
e i n?
- O he (Plea e
E lain) Te

751

Q218

cha ac e

If he e a
me hing
ab
he G ideb k
ha
did n
nd hel f l
he e i
me
ic
ha h ld be added
he G ideb k, lea e
e lain.

754

Q220

cha ac e

Wha can he NPDB d
make he ini ial
egi a i n
ce
ea ie ?

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

755

Q221

cha ac e

Wha can he NPDB d
make he egi a i n
ene al
ce ea ie ?

760

Q226_4_TEXT

cha ac e

D
belie e ha
he e i an
he
egi
e i
f j dgmen
c n ic i n e
,
ad e e ac i n e
,
medical mal ac ice
a men e
, ha i
c m a able
he
NPDB? Ye (Plea e P ide
De ail ) - Te

761

Q227

cha ac e

Plea e ha e an
he
c mmen ha
ha e
ega ding
e e ience i h an f
he
d c
e ice
ided b he NPDB.

764

Q230_1_TEXT

cha ac e

Ha e
e e ienced
an bene b he
me ge f
he NPDB and he
HIPDB? - Ye ( lea e
e lain) Te

766

Q231_1_TEXT

cha ac e

Ha e
e e ienced
an d a back d e
he
me ge f he NPDB
and he HIPDB? - Ye
( lea e
e lain) - Te

768

Q232_4_TEXT

cha ac e

Af e he me ge , a e
ecei ing all he
e
ha
ae
a h i ed
ecei e? N
(cla if he i e
e e ienced) - Te

769

Q232_5_TEXT

cha ac e

Af e he me ge , a e
ecei ing all he
e
ha
ae
a h i ed
ecei e? N

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

a licable (e lain) Te
770

Q233

cha ac e

Plea e ha e an
c mmen ha
ha e ega ding
e e ience i h
he me ge f he
NPDB and
he HIPDB.

772

Q235_7_TEXT

cha ac e

Wh ( ha
i i n) in
gani a i n
a e
c m liance i h
NPDB e i emen ? O he
( ecif ) - Te

774

Q236_4_TEXT

cha ac e

A e he e an bene
f he a e a i n
ce
gani a i n? Ye (Plea e e lain) Te

775

Q237

n me ic

A e he e an
di ad an age f he
a e ai n
ce
gani a i n? Selec ed Ch ice

776

Q237_4_TEXT

cha ac e

A e he e an
di ad an age f he
a e ai n
ce
gani a i n? - Ye
(Plea e
e lain) - Te

778

Q239

n me ic

T ha e en e e
he email eminde
hel f l?

782

Q240_4_TEXT

cha ac e

Did
gani a i n
ha e make an
igni can
change in i
anda d
eai n
c m l
ih
he ne a e a i n

1
4

N
Ye (Plea e e lain)

1
2
3
4
5
6

N
T
T
T
T
T

a all
a mall e en
me e en
a m de a e e en
a g ea e en
a e g ea e en

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ce ? - Ye (Plea e
e lain) - Te
784

Q243_1_TEXT

cha ac e

Ha he a e a i n
ce made a
diffe ence in
gani a i n
c m liance i h NPDB
e i emen ? - Ye ,
e lain h : - Te

786

Q244_6_TEXT

cha ac e

A e l f he
e i emen
a e
c m liance i h NPDB
e i emen , ha he e
been
an change in he
n mbe f e
f m
gani a i n
he
NPDB? - D n kn
(Plea e
e lain) - Te

788

Q245_6_TEXT

cha ac e

A e l f he
e i emen
a e
c m liance i h NPDB
e i emen , ha he e
been
an change in he
n mbe f e ie f m
gani a i n
he
NPDB? - D n kn
(Plea e
e lain) - Te

793

Q247_4_TEXT

cha ac e

I
gani a i n
a e a i n e ie ed b
a
legal c n el bef e i
i igned? - Ye (Plea e
e lain) - Te

794

Q248

cha ac e

If he e ha been an
he im ac f he
a e ai n
ce
n
gani a i n
aff
membe , lea e
e lain.

796

Q250_5_TEXT

cha ac e

Did
gani a i n
e he NPDB
be een

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

Jan a 2018 and
Decembe 2020 n
behalf f a
egi e ed NPDB
en i ? - O he (Plea e
E lain) Te
799

Q252_4_TEXT

cha ac e

F

h man
gani a i n did
agenc
ide
NPDB e ing
e ice be een
Jan a 2018 and
Decembe 2020? - D
n kn ( lea e
e lain) Te

800

Q253_1

cha ac e

Wha i he a e age
n mbe f NPDB
e ie ha
gani a i n made
e m n h be een
Jan a
2018 and Decembe
2020? - Plea e en e a
n mbe :

801

Q254_1

cha ac e

F

812

Q255_14_TEXT

cha ac e

F

824

Q258_12_TEXT

cha ac e

The QRXS clien
g am
ide
feedback ab
cce f l and
n cce f l
an ac i n . Which f
he f ll ing i e
ha e
enc n e ed
hile

h man
ac i i ne d
icall
e
e m n h? - T e a
n mbe :
ha
e f
gani a i n did
gani a i n
ide
e ing e ice
be een
Jan a 2018 and
Decembe 2020?
(Plea e elec all
ha a l .) - O he
(Plea e E lain) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

e ing he NPDB
ing he QRXS?
Selec all ha
a l . - O he ( lea e
ecif ) - Te
825

Q259

cha ac e

Wha a e he maj
h dle ha
ha e
e e ienced hen
c nd c ing ba ch
e ie n he
NPDB
em?

839

Q261_8_TEXT

cha ac e

U ing he cale
ided, lea e a e
e e ience ega ding
each f he f ll ing
a ec
f e ing he NPDB.
- O he (Plea e
E lain) Te

841

Q262_6_TEXT

cha ac e

H

d e
gani a i n b ain
NPDB inf ma i n
ab
heal h ca e
ac i i ne a lican ?
- O he
(Plea e E lain) - Te

848

Q264_7_TEXT

cha ac e

The la ime hi
ha ened, ha ac i n
did
ake? (Selec all ha
a l .) - O he ( lea e
e lain) - Te

855

Q266_7_TEXT

cha ac e

Wha d e
gani a i n d in he
e en f a
n n- e n e a
e (e.g.,
ee
e ec ing
a e
b he e a
n di cl
e f an
e
)? (Selec all ha
a l .) - O he ( lea e
e lain) - Te

861

Q270

cha ac e

Wha el e
ld
like
ee in he
NPDB

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

elf- e ice e
agen ?

f

863

Q272

cha ac e

Wha el e
ld
like add in he
NPDB
k
ce f
agen ?

865

Q274

cha ac e

I he e an hing el e
ha he NPDB can d
im
e
e e ience f
a an agen ?

e ing

866

Q275

cha ac e

If he e i an hing el e
ab
e
e e ience ha
ld like
ha e
ih ,
lea e en e i he e:

868

Q277_5_TEXT

cha ac e

Did
gani a i n
bmi a e
he
NPDB
be een Jan a 2018
and Decembe 2020 n
behalf
f a egi e ed NPDB
en i ? - O he (Plea e
E lain) - Te

871

Q279_4_TEXT

cha ac e

F

872

Q280_1

cha ac e

Wha i he a e age
n mbe f e
he NPDB
ha
gani a i n
bmi ed e m n h
be een
Jan a 2018 and
Decembe 2020? Plea e en e a
n mbe :

873

Q281_1

cha ac e

F

h man
gani a i n did
agenc
ide
NPDB e
ing
e ice be een
Jan a 2018 and
Decembe 2020? - D
n kn ( lea e
e lain) Te

h

man

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ac i i ne d
icall e
e m n h? - T e a
n mbe :
886

Q282_14_TEXT

cha ac e

F

ha
e f
gani a i n did
gani a i n
ide
e
ing e ice
be een
Jan a 2018 and
Decembe 2020?
(Plea e elec all
ha a l .) - O he
(Plea e E lain) - Te

898

Q285_12_TEXT

cha ac e

The QRXS clien
g am
ide
feedback ab
cce f l and
n cce f l
an ac i n . Which f
he f ll ing i e
ha e
enc n e ed
hile
e
ing
he NPDB
ing he QRXS?
Selec all
ha a l . - O he
( lea e ecif ) - Te

899

Q286

cha ac e

Wha a e he maj
h dle ha
ha e
e e ienced hen
bmi ing ba ch
e
he
NPDB?

914

Q288_9_TEXT

cha ac e

U ing he cale
ided, lea e a e
e e ience ega ding
each f he f ll ing
a ec
f e
ing
he
NPDB. - O he (Plea e
E lain)
- Te

916

Q290_1

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
Ad e e Ac i n Re
.

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

Plea e
ide
e ima ed
ime (in min e ) f
he f ll ing a ec
f he
e
ing
ce : Min e
en
c llec ing
inf ma i n ab
he
e
917

Q290_4

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
Ad e e Ac i n Re
.
Plea e
ide
e ima ed
ime (in min e ) f
he f ll ing a ec
f he
e
ing
ce : Min e
en ling he
e
he NPDB

918

Q290_5

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
Ad e e Ac i n Re
.
Plea e
ide
e ima ed
ime (in min e ) f
he f ll ing a ec
f he
e
ing
ce : - N
a licable ( lea e
e lain)

921

Q292_1_TEXT

cha ac e

Ha e an f he en i ie
ha
e e en e e
ided
i h an
Ad e e Ac i n
Cla i ca i n
e n e ha did n
c e nd
he
cla i ca i n in he
NPDB
em? - Ye
( lea e
ecif ) - Te

924

Q294_6_TEXT

cha ac e

While ling an ad e e
ac i n e
, if he

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

Ba i f Ac i n
e ne
ided b
he en i ie
e e en d n
c e nd
he Ba ic
f
Ac i n li ed in he
NPDB
em, ha d
icall d ? - O he
( lea e ecif ) - Te
925

Q295

cha ac e

If
ha e an
c mmen ab
inf ma i n e
he NPDB f ad
ac i n , lea e
hem he e:

he
he
ed
e e
ide

926

Q296

cha ac e

I he e an hing ha
he NPDB can d
im
e
e e ience f
e
ing a an agen ?

927

Q297

cha ac e

If he e i an hing el e
ab
e
ing
e e ience ha
ld like
ha e
ih ,
lea e en e i he e:

930

Q300_4_TEXT

cha ac e

A e he e an bene
f he a e a i n
ce
gani a i n? Ye (Plea e e lain) Te

932

Q301_4_TEXT

cha ac e

A e he e an
di ad an age f he
a e ai n
ce
gani a i n? - Ye
(Plea e
e lain) - Te

937

Q305_4_TEXT

cha ac e

Did
gani a i n
ha e make an
igni can
change in i
anda d
eai n
c m l
ih
he ne a e a i n

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ce ? - Ye (Plea e
e lain) - Te
941

Q307

cha ac e

If he e ha been an
he im ac f he
NPDB
a e ai n
ce
n
a an a h i ed
agen
n he gani a i n
e e en , lea e
e lain.

943

Q309_5_TEXT

cha ac e

Ha e
e e e
ed
a medical mal ac ice
a men
he NPDB
n behalf f
gani a i n? - O he
(Plea e e lain) - Te

945

Q310_5_TEXT

cha ac e

Ha
gani a i n
e e e
ed a medical
mal ac ice a men
he NPDB? - O he
(Plea e
e lain) - Te

946

Q311_1

cha ac e

A
e
b

ha e n
ed
he NPDB,

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi medical
mal ac ice
a men e
he
NPDB
ha he can
an e he ele an
e
e i n
ela ed
ch e
. - Fi
name:
947

Q311_4

cha ac e

A
e
b

ha e n
ed
he NPDB,

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

bmi medical
mal ac ice
a men e
he
NPDB
ha he can
an e he ele an
e
e i n
ela ed
ch e
. - La
name:
948

Q311_5

cha ac e

A
e
b

ha e n
ed
he NPDB,

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi medical
mal ac ice
a men e
he
NPDB
ha he can
an e he ele an
e
e i n
ela ed
ch e
.Tele h ne n mbe :
949

Q311_6

cha ac e

A
e
b

ha e n
ed
he NPDB,

gani a i n ha ,
lea e
ide he
name and
c n ac inf ma i n f
he e n in
gani a i n h
bmi medical
mal ac ice
a men e
he
NPDB
ha he can
an e he ele an
e
e i n
ela ed
ch e
. - Email
add e :
952

Q313_8_TEXT

cha ac e

Which f he f ll ing
ca eg ie be
cha ac e i e
gani a i n? - O he
(Plea e
E lain) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

959

Q315_11_TEXT

cha ac e

Y

indica ed ha
gani a i n ha ne e
e
ed a medical
mal ac ice a men
he
NPDB. Wha e e he
ea n f n
e
ing?
(Selec all ha a l .) O he (Plea e E lain)
- Te

978

Q323_8_TEXT

cha ac e

U ing he cale
ided, lea e a e
e e ience ega ding
each f he f ll ing
a ec
f e
ing
mal ac ice a men
he NPDB. O he (Plea e E lain)
- Te

980

Q325

cha ac e

E lain he ea n f
ch ice ab
he
ime
ela ed f m hen a
medical mal ac ice
a men i
made
he da e
le a e
he
NPDB.

981

Q326_1

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
Medical Mal ac ice
Pa men Re
. Plea e
ide
e ima ed ime (in
min e ) f he
f ll ing
a ec f he e
ing
ce : - Min e
en
c llec ing inf ma i n
ab
he e

982

Q326_4

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

c m le e a
ical
Medical Mal ac ice
Pa men Re
. Plea e
ide
e ima ed ime (in
min e ) f he
f ll ing
a ec f he e
ing
ce : - Min e
en
ling he e
he
NPDB
1001 Q329_1_TEXT

cha ac e

Sh ld an change be
made
he li f
Gene al
Na e f Allega i n
f medical mal ac ice
a men ? - Ye ,
addi i nal e n e
h ld be
added ( lea e ecif ) Te

1002 Q329_4_TEXT

cha ac e

Sh ld an change be
made
he li f
Gene al
Na e f Allega i n
f medical mal ac ice
a men ? - Ye ,
e i ing e n e
h ld be
changed ( lea e
ecif ) - Te

1003 Q329_5_TEXT

cha ac e

Sh ld an change be
made
he li f
Gene al
Na e f Allega i n
f medical mal ac ice
a men ? - N
change a e needed
( lea e
elab a e) - Te

1012 Q332_1_TEXT

cha ac e

Sh ld an change be
made
he li f
S eci c
Allega i n f
mal ac ice a men ?
- Ye ,
addi i nal e n e
h ld be added
( lea e
ecif ) - Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

1013 Q332_4_TEXT

cha ac e

Sh ld an change be
made
he li f
S eci c
Allega i n f
mal ac ice a men ?
- Ye ,
e i ing e n e
h ld be changed
( lea e
ecif ) - Te

1014 Q332_5_TEXT

cha ac e

Sh ld an change be
made
he li f
S eci c
Allega i n f
mal ac ice a men ?
- N change
a e needed ( lea e
elab a e) - Te

1027 Q335_1_TEXT

cha ac e

Sh ld an change be
made
he li f
O c me
Re n e f
mal ac ice a men ?
- Ye ,
addi i nal e n e
h ld be added
( lea e
ecif ) - Te

1028 Q335_4_TEXT

cha ac e

Sh ld an change be
made
he li f
O c me
Re n e f
mal ac ice a men ?
- Ye ,
e i ing e n e
h ld be eded
( lea e
ecif ) - Te

1029 Q335_5_TEXT

cha ac e

Sh ld an change be
made
he li f
O c me
Re n e f
mal ac ice a men ?
- N change
a e needed ( lea e
elab a e) - Te

1030 Q336

cha ac e

If
ha e an
c mmen ab
inf ma i n e
he NPDB f

he
he
ed

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

mal ac ice
a men , lea e
ide hem he e:
1037 Q338_6_TEXT

cha ac e

In
gani a i n,
h i named in
medical
mal ac ice ca e ? O he (Plea e E lain)
- Te

1044 Q339_8_TEXT

cha ac e

Medical mal ac ice
a men can be made
d e
man ea n , ch a ,
j dgmen , e lemen ,
and
he ea n . Which f
he e ea n a l
he
e
ha e led?
(Selec all ha a l .) O he (Plea e E lain):
- Te

1051 Q341_8_TEXT

cha ac e

The la ime hi
ha ened, ha ac i n
did
ake? (Selec all ha
a l .) - O he ( lea e
e lain) - Te

1053 Q342_6_TEXT

cha ac e

When bmi ing a
mal ac ice a men
e
he NPDB, d e
gani a i n e he
NPDB
e
f
a ding
e ice in de
end
an
elec nic e
he
a
ia e a e
a h i ? - O he
(Plea e E lain) - Te

1057 Q346_10_TEXT

cha ac e

Whe e did
lea n
ab
he NPDB fee
ai e ? O he (Plea e e lain) Te

1061 Q350

cha ac e

If he e a an
he
im ac f he NPDB
fee

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

ai e n
gani a i n, lea e
e lain.
1064 Q353

cha ac e

In addi i n
he fee
ai e
ing all
eligible en i ie in
di a e c eden ialing,
ha
el e c ld he NPDB
ha e d ne d ing he
COVID-19
andemic?

1065 Q354

cha ac e

Wha c ld he NPDB
d
hel
gani a i n
e a ef f
e
andemic , di a e ,
and
eme gencie ?

1083 Q361_8_TEXT

cha ac e

U ing he cale
ided, lea e a e
e e ience ega ding
each f he f ll ing
a ec
f e
ing JOCR
he NPDB. - O he
(Plea e
E lain) - Te

1085 Q363

cha ac e

E lain he ea n f
ch ice ab
he
ime
ela ed f m hen a
e
able ac i n
cc
he da e
le a
JOCR
he NPDB.

1086 Q364_1

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
JOCR. Plea e
ide
e ima ed ime (in
min e )
f he f ll ing
a ec f he e
ing
ce : - Min e
en c llec ing

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

inf ma i n
ab
he e
1087 Q364_4

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
JOCR. Plea e
ide
e ima ed ime (in
min e )
f he f ll ing
a ec f he e
ing
ce : - Min e
en ling he e
he
NPDB

1088 Q364_5

cha ac e

We a e in e e ed in
lea ning ab
he ime
i
ake
gani a i n
c m le e a
ical
JOCR. Plea e
ide
e ima ed ime (in
min e )
f he f ll ing
a ec f he e
ing
ce : - N
a licable ( lea e
e lain)

1098 Q367_1_TEXT

cha ac e

Sh ld an change be
made
he li f
JOCR Ac
Omi i n e n e ?
- Ye , addi i nal
e ne
h ld be added
( lea e ecif ) - Te

1099 Q367_4_TEXT

cha ac e

Sh ld an change be
made
he li f
JOCR Ac
Omi i n e n e ?
- Ye , e i ing
e ne
h ld be changed
( lea e ecif ) - Te

1100

cha ac e

Sh ld an change be
made
he li f
JOCR Ac
Omi i n e n e ?
- N change a e

Q367_5_TEXT

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

needed
( lea e elab a e) Te
1101

Q368

cha ac e

If
ha e an
he
c mmen ab
he
inf ma i n e
ed
he NPDB f JOCR
Ac
Omi i n de c i i n ,
lea e
ide hem
he e:

1108

Q370_8_TEXT

cha ac e

The la ime hi
ha ened, ha ac i n
did
ake? (Selec all ha
a l .) - O he ( lea e
e lain) - Te

1109

Q371

cha ac e

If
ha e an
he
c mmen ab
e e ience f ling
JOCR
he NPDB,
lea e
ide hem he e:

1110

Q373

cha ac e

If
ha e an
c mmen ab
he
NPDB
hi
e , lea e feel f ee
en e hem he e. F
in ance,
migh
men i n a ec f
e e ience i h he
NPDB
ie
ab
he
NPDB ha
feel
ha hi
e did n
ca
e.

1118

Q378_6

n me ic

The NPDB
ide
de ailed nline
in c i n
egi e ed end
ega ding he QRXS
le f ma
eci ca i n . U ing
he a ing cale bel ,
lea e a e
a i fac i n i h each
f he
f ll ing QRXS
eci ca i n
ided

1
2
3
4
5

Ve Sa i ed
Sa i ed
Nei he Sa i ed N
Di a i ed
Di a i ed
Ve Di a i ed

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

b he
NPDB: - Pa
d
Change S eci ca i n
1121

Q380

cha ac e

The e a e man
c mme cial and ence XML
alida
a ailable.
Which XML alida
d e
gani a i n e
f
ce ing he
NPDB QRXS
bmi i n and/
e n e le ? If
ible,
al
ide
ea n f
ing ha
XML
alida .

1127

Q384_5_TEXT

cha ac e

D e
gani a i n
im lemen he QRXS
API? D n kn ( lea e
e lain) - Te

1134

Q386_7_TEXT

cha ac e

A

1136

Q387_11_TEXT

cha ac e

A men i ned ab e,
he NPDB
ide a
6-m n h
n ice f making an
change
he QRXS.
Wha
ld be
gani a i n
efe ed ime f
all ing change
he
NPDB QRXS
em?
-D n
kn (Plea e e lain) Te

e en , he NPDB
ide a 6-m n h
n ice f
making an change
he QRXS. Wh
inf m
ab
im ending
change in he QRXS?
(Selec all
ha a l .) - D n
kn ( lea e e lain) Te

OMB Number: 0915-XXXX; Expiration date: XX/XX/202X

1139

Q390

cha ac e

Wha a e he c mm n
h dle in in e facing
ih
he NPDB QRXS?

1140

Q391

cha ac e

Wha can he NPDB d
make he QRXS
m e ef l
?

1141

Q392

cha ac e

If
ha e an
he
c mmen ab
NPDB
machine- -machine
in e face (QRXS),
lea e feel
f ee en e hem he e.