Form 21 Continuous Query

Continuous Query Enrollment Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Organization Continuous Below
Text
Description Query (1) Organization Entry
Type

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

Name of
Occupation

Continuous Beside
Text
Query (1) Profession or entry
Field of
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
“Name of
Occupation” if the
selected profession
or field of licensure
requires specialty
information.

Specialty

Continuous Beside
Drop List
Query (1) Profession or
Field of
Licensure

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

“Name of
Occupation” is
displayed in place of
“Specialty” if the
selected profession
or field of licensure
does not require
information for a
specialty.

FEIN (Federal Continuous Below
Text
Employer
Query (1) checkbox
Entry
Identification
"Does the
Number)
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.

UPIN
Continuous Below FEIN
(Unique
Query (1) text entry
Physician
Identification
Numbers)

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.

Text
Entry

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Cancel on

Continuous Below
Query (1) Privileged
Staff or
Employee
radio button

Text
Entry

The field is displayed
if the user selects
Temporary or Locum
Tenens or Applicant
radio buttons.

Privileges Staff or
Employee option
does not require a
cancellation date.

Entity
Selection

Continuous After step 1
Query (2) Subject
Information

Check
boxes

The Entity Selection
section is only
displayed if the user is
authorized to act as an
agent to query on
behalf of other
entities.

All entities are listed
for which the user is
authorized to query
are listed.

Enter Subject Continuous After
ID or
Query (3) Practitioner
Department
section on
for these
the Review
enrollment(s)
panel

Checkbox The field is displayed if
the Entity Selection
panel is displayed.

Subject
Continuous Below Enter Text
Identification Query (3) Subject ID or Entry
Number
Department
for these
enrollment(s)

The field is displayed
if the user selects the
checkbox Enter Subject
ID or Department for
these enrollment(s).

Department

The field is displayed
if the user selects the
checkbox Enter Subject
ID or Department for
these enrollment(s) and
the entity has added
departments in their
profile.

Continuous Beside
Drop List
Query (3) Subject
Identification
Number

State Changes
Label

PDF Name

Item Type

Trigger

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

Continuous Modal
Query

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

Subjects Available

Continuous Table
Query

When the user selects the option to
enroll from their subject database,
the summary table of the subjects
with previously saved subject
information is displayed. The user
select one or more names from the
table, then select continue to enter
payment information.

Select an Profession Continuous Modal
or Field of
Query
Licensure

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

Continuous Text Entry
Query

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

License Number

Continuous Text Entry
Query

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