Form 13 Civil Judgment

Civil Judgment Forms and Instructions

Non-visible Questions
Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Civil
Below "Is this
Judgment person
(1)
deceased?"

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

Organization
Description

Civil
Below
Judgment Organization
(1)
Type

Text Entry

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

Specialty

Civil
Beside Profession Text entry
Judgment or Field of
(1)
Licensure

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

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

Description

Civil
Beside Profession Drop List
Judgment 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.

Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

FEIN (Federal
Employer
Identification
Number)

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

The field is displayed
in the individual
report form 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.

UPIN (Unique
Physician
Identification
Numbers)

Civil
Below FEIN text
Judgment entry
(1)

Text Entry

The field is displayed
in the individual
report form 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.

FDA (Federal
Food and Drug
Administration)

Civil
Below checkbox Text Entry
Judgment "Does the subject
(1)
have a FDA or
CLIA
identification
number?"

The field is displayed
in the organization
report form if the
user selects the
checkbox for "Does
the subject have a
FDA or CLIA
identification
number?"

Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.

CLIA (Clinical
Laboratory
Improvement
Act)

Civil
Below text entry
Judgment FDA (Federal
(1)
Food and Drug
Administration)

The field is displayed
in the organization
report form if the
user selects the
checkbox for "Does
the subject have a
FDA or CLIA
identification
number?"

Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.

Text Entry

Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Type of
Affiliation

Civil
Below "Is the
Judgment 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

Civil
Below Type of
Judgment 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

Civil
Below "Is the
Judgment 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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

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

Civil
Below Country
Judgment
(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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Address Line 2

Civil
Below Address
Judgment
(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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

City

Civil
Below Address
Judgment 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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

State

Civil
Below City
Judgment
(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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

ZIP

Civil
Below State
Judgment
(1)

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

Description

Civil
Below “Act or
Judgment Omission”
(2)

Text Entry

Date of Appeal

Civil
Below "Is the
Judgment Action on
(2)
Appeal"

Text Entry The field is displayed
if the user selects
the "Yes?" radio
button for "Is the
Action on Appeal?"

Years

Civil
Beside Sentence
Judgment of Judgment
(2)
drop list

Drop List

Other

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

The field is displayed
if the user selects an
act or omission that
requires a
description.

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
does not apply,
then Years, Months
and Days drop lists
are displayed.

Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Months

Civil
Beside Years
Judgment
(2)

Drop List

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
does not apply,
then Years, Months
and Days drop lists
are displayed.

Days

Civil
Beside Months
Judgment
(2)

Drop List

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
does not apply,
then Years, Months
and Days drop lists
are displayed.

Hours

Civil
Beside Months
Judgment
(2)

Drop List

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
applies, then an
Hours drop list is
displayed.

State Changes
Label

PDF Name

Item Type

Trigger

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

Civil Judgment

Modal

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

Profession or
Field of
Licensure

Civil Judgment

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.

Other Name
Civil Judgment
for Occupation

Text Entry

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

License
Number

Civil Judgment

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?" For
organization reports, the label is “Does the
organization have a license?”

Select an Act
or Omission

Civil Judgment

Modal

When the user sets focus on the Act or Omission 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 act
or select an act from the list without searching. The
modal is hidden once the user selects an act from the
list. The user's selection populates the Act or
Omission text entry.