Form 5 Peer Review Organization

Peer Review Organization Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Peer Review Below "Is this
Organization person
(1)
deceased?"

Text Entry The field is displayed
if the user selects
the "Yes" radio
button for "Is this
person deceased?"

Organization
Description

Peer Review Below
Organization Organization
(1)
Type

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

Specialty

Peer Review Beside Profession Text entry The field is displayed
Organization or Field of
if the user selects a
(1)
Licensure
profession or field of
licensure that does
not require
information for a
specialty.

“Specialty” is
displayed in place
of “Description” if
the selected
profession or field
of licensure
requires specialty
information.

Description

Peer Review Beside Profession Drop List
Organization or Field of
(1)
Licensure

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.

FEIN (Federal
Employer
Identification
Number)

Peer Review Below checkbox Text Entry
Organization "Does the subject
(1)
have an FEIN, or
UPIN
identification
number?"

The field is displayed
if the user selects
the checkbox
for "Does the subject
have an FEIN, or
UPIN identification
number?"

Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

UPIN (Unique
Physician
Identification
Numbers)

Peer Review Below FEIN text
Organization entry
(1)

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.

Type of
Affiliation

Peer Review Below "Is the
Organization practitioner
(1)
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

Peer Review Below Type of
Organization Affiliation
(1)

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

Peer Review Below "Is the
Organization practitioner
(1)
affiliated with a
health care
entity?"
checkbox

Drop List

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.

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

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Address

Peer Review Below Country
Organization
(1)

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

Peer Review Below Address
Organization
(1)

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

Peer Review Below Address
Organization Line 2
(1)

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

Peer Review Below City
Organization
(1)

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.

ZIP

Peer Review Below State
Organization
(1)

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.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Description

Peer Review Below an a
Organization finding requiring
(2)
a description

Text Entry The field is displayed
if the user selects a
finding that requires
a description.

Description

Peer Review Below Basis of
Organization Finding(s)
(2)

Text Entry The field is displayed
if the user selects a
basis of finding that
requires a
description.

Other

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy

Peer Review
Organization

Modal

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

Select a
Profession or
Field of
Licensure

Peer Review
Organization

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

Peer Review
Organization

Text Entry

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

License
Number

Peer Review
Organization

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 Finding

Peer Review
Organization

Modal

When the user sets focus on the Basis for Finding(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 finding or select an finding from the list
without searching. The modal is hidden once the user
selects a finding from the list. The user's selection
populates the Basis for Finding(s) text entry.