DEA Federal Licensure

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DEA_Federal Licensure Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Date of Death

DEA_Federal Below "Is this
Text Entry
Licensure (1) person deceased?"

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

Organization
Description

DEA_Federal Below
Text Entry
Licensure (1) Organization Type

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

Description

DEA_Federal Beside Profession
Licensure (1) or Field of
Licensure

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

Text entry

Other

“Description” is
displayed in place
of “Specialty” if
the selected
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)”

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Drop List

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

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

Specialty

DEA_Federal Beside Profession
Licensure (1) or Field of
Licensure

FEIN (Federal
Employer
Identification
Number)

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

The field is
Selecting the
displayed in the checkbox displays
individual form
FEIN and UPIN
if the user selects text entry fields.
the checkbox
for "Does the
subject have an
FEIN, or UPIN
identification
number?"

UPIN (Unique
Physician
Identification
Numbers)

DEA_Federal Below FEIN text
Licensure (1) entry

Text Entry

The field is
Selecting the
displayed in the checkbox displays
individual form
FEIN and UPIN
if the user selects text entry fields.
the checkbox for
"Does the
subject have an
FEIN, or UPIN
identification
number?"

FDA (Federal
Food and Drug
Administration)

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

The field is
Selecting the
displayed in the checkbox displays
organization
FDA and CLIA,
report form if the and text entry
user selects the fields.
checkbox
for "Does the
subject have a
FDA or CLIA
identification
number?"

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

CLIA (Clinical
Laboratory
Improvement
Act)

DEA_Federal Below text entry
Text Entry
Licensure (1) FDA (Federal Food
and Drug
Administration)

The field is
Selecting the
displayed in the checkbox displays
organization
FDA and CLIA,
report form if the and text entry
user selects the fields.
checkbox
for "Does the
subject have a
FDA or CLIA
identification
number?"

Type of
Affiliation

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

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

Drop List

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
Entity Name

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

DEA_Federal Below Type of
Licensure (1) Affiliation

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?"

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?”
Country

DEA_Federal Below Entity Name Drop List
Licensure (1)

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. United
States is the
default selection.

Label
Address

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

DEA_Federal 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?"

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?”
Address Line 2

DEA_Federal Below Address
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?”

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

Label
City

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

DEA_Federal Below Address
Licensure (1) Line 2

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?"

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?”
State

DEA_Federal Beside City
Licensure (1)

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?"
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
ZIP

PDF Name
(step)

Location

DEA_Federal Below City
Licensure (1)

Response
Input Item

Visibility Trigger

Other

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?"

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?”
Description

DEA_Federal Below an action
Licensure (2) requiring a
description

Text Entry

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

Description

DEA_Federal Below Basis for
Licensure (2) Action(s)

Text Entry

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

Years

DEA_Federal Below the radio
Licensure (2) button “A specific
period of time”

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.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Months

DEA_Federal Beside Years
Licensure (2)

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.

Days

DEA_Federal Beside Months
Licensure (2)

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.

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)

Is reinstatement DEA_Federal Below “How long
automatic after Licensure (2) will it remain in
this period of
effect?”
time?

Date of Appeal

DEA_Federal Below Is the action Text Entry
Licensure (2) on appeal?

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

DEA_Federal
Licensure

Modal

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

Select an
Profession or
Field of
Licensure

DEA_Federal
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)

DEA_Federal
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

DEA_Federal
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?"

Select an
Profession or
Field of
Licensure

DEA_Federal
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.

Label

PDF Name

Item Type

Trigger

Name of
School or
Institution

DEA_Federal
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

Completion
Year

DEA_Federal
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

DEA_Federal
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.