Form 14 Exclusion or Debarment

Exclusion or Debarment Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item
Text
Entry

Visibility Trigger

Other

Date of Death

Exclusion or
Debarment(1)

Below "Is this
person
deceased?"

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

Organization
Description

Exclusion or
Debarment(1)

Below
Text
Organization Type Entry

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

Specialty

Exclusion or
Debarment(1)

Beside Profession
or Field of
Licensure

Text
entry

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

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

Description

Exclusion or
Debarment(1)

Beside Profession
or Field of
Licensure

Drop List

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

“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)

Exclusion or
Debarment(1)

Below checkbox
Text
"Does the subject Entry
have an FEIN, or
UPIN identification
number?"

The field is
displayed in the
individual 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)

Exclusion or
Debarment(1)

Below FEIN text
entry

Text
Entry

The field is
displayed in the
individual 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)

Exclusion or
Debarment(1)

Below checkbox
Text
"Does the subject Entry
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.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

CLIA (Clinical
Laboratory
Improvement
Act)

Exclusion or
Below text entry
Text
Debarment(1)) FDA (Federal Food Entry
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.

Type of
Affiliation

Exclusion or
Debarment(1)

Below "Is the
practitioner
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

Exclusion or
Debarment(1)

Below Type of
Affiliation

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

Exclusion or
Debarment(1)

Below "Is the
practitioner
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. United
States is the
default selection.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Address

Exclusion or
Debarment(1)

Below Country

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

Exclusion or
Debarment(1)

Below Address

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

Exclusion or
Debarment(1)

Below Address
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

Exclusion or
Debarment(1)

Below City

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. .

Label

PDF Name
(step)

Location

Below State

Response
Input
Item

Visibility Trigger

Other

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.

ZIP

Exclusion or
Debarment(1)

Description

Exclusion or
Below an action
Debarment (2) that requires a
description

Text
Entry

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

Description

Exclusion or
Below Basis of
Debarment (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

Exclusion or
Below “How long
Debarment (2) will it remain in
effect?”

Text
Entry

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.

Period of time
type

Exclusion or
Below “How long
Debarment (2) will it remain in
effect?”

Drop List

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.

Label

Date of Appeal

PDF Name
(step)

Location

Exclusion or
Below Is the
Debarment (2) action on appeal?

Response
Input
Item
Text
Entry

Visibility Trigger

The field is
displayed if the
user selects Yes
option for “Is the
action on appeal?”

Other

State Changes
Label

PDF Name

Item Type

Trigger

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

Exclusion or
Debarment

Modal

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

Select a
Profession or
Field of
Licensure

Exclusion or
Debarment

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

Exclusion or
Debarment

Text Entry

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

License
Number

Exclusion or
Debarment

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

Exclusion or
Debarment

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.