Form 1 Correction Revision-to-Action Void Notice of Appeal

Correction, Revision-to-Action, Void, Notice of Appeal Forms and Instructions

Non-visible Questions
For Correction and Revision-to-Action the Non-visible questions will be the same as the nonvisible questions for the initial report.
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Are you sure
Correction, Lower part of the
you want to
Revision-to- first page
void this report? Action,
Void, Notice
of Appeal
(Void
Report)

Radio
buttons
“Yes” and
“No”

If the report has
completed a dispute
resolution review
with a decision that
the report should
remain unchanged
then the input items
are displayed

If the report does
not qualify under
the conditions, the
fields are not
displayed.

Are you sure
Correction, Lower part of the
you want to
Revision-to- first page
void this report? Action,
Void, Notice
of Appeal
(Void
Report)

Radio
buttons
“No, I want
to correct
it.” and
“Yes, I
want to
void it.”

If the report has
completed a dispute
resolution review
with a decision that
the report should be
corrected then the
input items are
displayed.

If the report does
not qualify under
the conditions, the
fields are not
displayed.

Please explain:

Text entry

If the user selects the If displayed, then
radio button that the the field is required.
report was
erroneously
submitted then the
text entry is
displayed.

Correction, Below the first
Revision-to- radio button
Action,
Void, Notice
of Appeal
(Void
Report–
Why are
you voiding
this report?)

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other
If displayed, then
the field is required.
The label is changed
to “The Secretary
determined that this
report meets the
NPDB reporting
requirements. Why
do you disagree?” if
the report has a
dispute resolution
decision that the
report should
remain unchanged.
The label is changed
to “The Secretary
determined that this
report should be
corrected. Why are
you voiding it?” if
the report has a
dispute resolution
decision that the
report should be
corrected.

Please explain:

Correction, Below the second Text entry
Revision-to- radio button
Action,
Void, Notice
of Appeal
(Void
Report –
Why are
you voiding
this report?)

If the user selects the
radio button that the
action should not
have been reported
then the text entry is
displayed.

Please explain:

Correction, Below the third
Revision-to- radio button
Action,
Void, Notice
of Appeal
(Void
Report –
Why are
you voiding
this report?)

If the user selects the If displayed, then
radio button that the the field is required.
action was reversed
then the text entry is
displayed.

Text entry

State Changes
For Correction and Revision-to-Action the state changes will be the same as the state
changes for the initial report.
Label

PDF Name

Item Type

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

Correction, Modal
Revision-toAction,
Void,
Notice of
Appeal

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