State Licensure or Certification

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State Licensure or Certification Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

State
Below "Is this
Licensure (1) person
deceased?"

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

Organization
Description

State
Below
Licensure (1) Organization
Type

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

Description

State
Beside
Licensure (1) Profession or
Field of
Licensure

Text Entry The field is displayed
if the user selects a
profession or field of
licensure that does
not have a specialty.

“Description is
displayed in place
of “Specialty” if the
profession or field
of licensure does
not have a
specialty. The label
is “Description” if
the selected
profession or field
of licensure
requires a
description.
Otherwise, the label
is “Description
(Optional)”

Specialty

State
Beside
Licensure (1) Profession or
Field of
Licensure

Drop List

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

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

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

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.

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.

Text Entry 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.

FEIN (Federal
Employer
Identification
Number)

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

UPIN (Unique
Physician
Identification
Numbers)

State
Below FEIN
Licensure (1) text entry

FDA (Federal
State
Below
Food and Drug Licensure (1) checkbox
Administration)
"Does the
subject have a
FDA or CLIA
identification
number?"

CLIA (Clinical
Laboratory
Improvement
Act)

State
Below text
Text Entry
Licensure (1) entry FDA
(Federal 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.

Label
Type of
Affiliation

Entity Name

PDF Name
(step)

Location

Response
Input Item

State
Below the
Drop List
Licensure (1) checkbox "Is
the
practitioner
affiliated with a
health care
entity?" or” Is
the
organization
affiliated with a
health care
entity?”

State
Below Type of
Licensure (1) Affiliation

Visibility Trigger

Other

For an individual
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"

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

For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

Text Entry For an individual
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"
For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

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
For an individual
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"

Country

State
Below Entity
Licensure (1) Name

Drop List

Address

State
Below Country
Licensure (1)

Text Entry For an individual
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"

Other

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries. United
For an organizational States is the default
selection.
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

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

Label
Address Line 2

PDF Name
(step)

Location

State
Below Address
Licensure (1)

Response
Input Item

Visibility Trigger

Text Entry For an individual
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"
For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

City

State
Below Address Text Entry For an individual
Licensure (1) Line 2
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"
For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

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

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

Label
State

PDF Name
(step)

Location

State
Beside City
Licensure (1)

Response
Input Item

Visibility Trigger

Other

Drop List

For an individual
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"

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

For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”
ZIP

State
Below City
Licensure (1)

Text Entry For an individual
report, the field is
displayed if the user
selects the checkbox
"Is the practitioner
affiliated with a
health care entity?"
For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

Was the action State
Below Adverse Radio
taken against a Licensure (2) Action(s) Taken buttons
multi-state
license?

For an individual
report, the fields are
displayed if the user
selects a type of
professional license
that has a multistate license.
Options are “Yes”
and “No”

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

If the selected
profession does not
have a multi-state
license then this
option is not
displayed.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Description

State
Below an
Licensure (2) action
requiring a
description

Description

State
Below Basis for Text Entry The field is displayed
Licensure (2) Action(s)
if the user selects a
basis for action that
requires a
description.

Years

State
Below the
Text Entry
Licensure (2) radio button “A
specific period
of time”

Months

State
Beside Years
Licensure (2)

Days

Other

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

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
text entries for
Years, Months and
Days.

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
text entries for
Years, Months and
Days.

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

Selecting the radio
button displays the
text entries for
Years, Months and
Days.

Is
State
reinstatement Licensure (2)
automatic after
this period of
time?

Below “How
long will it
remain in
effect?”

Radio
Buttons

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

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

Label

PDF Name
(step)

Is the adverse State
action
Licensure (2)
specified in this
report based
on the
subject’s
professional
competence or
conduct, which
adversely
affected, or
could have
adversely
affected, the
health or
welfare of
patient(s)?

Location

Response
Input Item

Below “Is
Radio
reinstatement Buttons
automatic after
this period of
time?”

Date of Appeal State
Below Is the
Licensure (2) action on
appeal?

Visibility Trigger

Other

The fields are
displayed if the user
selects a license
profession of
Physician (MD),
Physician (DO) or
Dentist for the
practitioner in
Subject Information

Available options
are “Yes” and “No”

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

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number:
0906-0081
Expiration
Date:
mm/dd/yyyy

State Licensure

Modal

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

Select up to 5
actions

State Licensure

Multi-select
Drop List

If the user selects a profession and state which has a
multi-state license, the question “Was the action
taken against a multi-state license?” is displayed with
“Yes” and “No” radio buttons. The list of actions
displayed for selection is dynamic, depending on the
user’s selection.

Select a
Profession or
Field of
Licensure

State Licensure

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.

Description
(Optional)

State Licensure

Text Entry

Text entry is disabled until the user selects a
profession or field of licensure that allows or requires
a description.

License
Number

State Licensure

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?"

Name of
School or
Institution

State Licensure

Text Entry

Names of School or Institution and Completion Year
text entries are disabled by default. When the user
selects a health care-related Profession or Field of
Licensure, the Name of School or Institution and
Completion Year are enabled. If the user selects a
profession that is not related to health care, entries
for the Name of School or Institution and Completion
Year are not allowed, so Name of School or
Institution and Completion Year are cleared and
hidden. Subsequent selection of a health care-related
profession redisplays both fields

Label

PDF Name

Item Type

Trigger

Completion
Year

State Licensure

Text Entry

Names of School or Institution and Completion Year
text entries are disabled by default. When the user
selects a health care-related Profession or Field of
Licensure, the Name of School or Institution and
Completion Year are enabled. If the user selects a
profession that is not related to health care, entries
for the Name of School or Institution and Completion
Year are not allowed, so Name of School or
Institution and Completion Year are cleared and
hidden. Subsequent selection of a health care-related
profession redisplays both fields

Select a Basis
for Action

State Licensure

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.