Form 8 Professional Society

Professional Society Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Professional Below "Is this
Society (1) person
deceased?"

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

Organization
Description

Professional Below
Society (1) Organization
Type

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

Specialty

Professional Beside Profession Text entry The field is displayed
Society (1) or Field of
if the user selects a
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

Professional Beside Profession Drop List
Society (1) or Field of
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)

Professional Below checkbox Text Entry
Society (1) "Does the subject
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

UPIN (Unique
Physician
Identification
Numbers)

Professional Below FEIN text
Society (1) entry

Type of
Affiliation

Professional Below "Is the
Drop List
Society (1) practitioner
affiliated with a
health care
entity?" checkbox

Entity Name

Professional Below Type of
Society (1) Affiliation

Country

Professional Below "Is the
Drop List
Society (1) practitioner
affiliated with a
health care
entity?" checkbox

Visibility Trigger

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

Other
Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

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.

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.

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

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State, and ZIP
entries. United
States is the default
selection.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Address

Professional Below Country
Society (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

Professional Below Address
Society (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

Professional Below Address
Society (1) Line 2

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

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State, and ZIP
entries.

State

Professional Below City
Society (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

Professional Below State
Society (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

Other

Description

Professional Below an action
Society (2) requiring a
description

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

Description

Professional Below Basis of
Society (2) Action(s)

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

Period of time
number

Professional Below “How long Text Entry The field is displayed
Society (2) will it remain in
if the user selects “A
effect?”
specific period of
time” option for
“How long will it
remain in effect?”

Selecting the radio
button displays the
number text entry
and type of time
period drop list.

Period of time
type

Professional Below “How long Drop List
Society (2) will it remain in
effect?”

The field is displayed
if the user selects “A
specific period of
time” option for
“How long will it
remain in effect?”

Selecting the radio
button displays the
number text entry
and type of time
period drop list.

The fields are
displayed if the user
selects “A specific
period of time” for
“Is reinstatement
automatic after this
period of time?

Available options
are “No,” “Yes” and
“Yes with
conditions
(Requires a Revision
to Action report
when status
changes)

Is
Professional Below “How long Radio
reinstatement Society (2) will it remain in
Buttons
automatic after
effect?”
this period of
time?

Date of Appeal

Professional Below Is the
Text Entry The field is displayed
Society (2) action on appeal?
if the user selects
Yes option for “Is the
action on appeal?”

State Changes
Label

PDF Name

Item Type

Trigger

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

Professional
Society

Modal

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

Select a
Profession or
Field of
Licensure

Professional
Society

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

Professional
Society

Text Entry

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

License
Number

Professional
Society

Text Entry

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

Select a Basis
for Action

Professional
Society

Modal

When the user sets focus on the Basis for Action(s)
text entry, the modal to select an act is displayed and
focus is set on the Search text entry. The user can
enter text in the Search text box to find a
specific basis or select a basis from the list without
searching. The modal is hidden once the user selects
a basis from the list. The user's selection populates
the Basis for Action(s) text entry.