Accreditation

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Accreditation Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Organization
Description

Accreditation Below
(1)
Organization
Type

FDA (Federal
Food and Drug
Administration)

Accreditation Below
Drop List
(1)
checkbox
"Does the
subject have a
FDA or CLIA
identification
number?"

Location

Response Visibility Trigger
Input
Item

Other

Text Entry The field is
displayed if the
user selects an
organization type
that requires a
description.
The field is
displayed if the
user selects the
checkbox for
"Does the
subject have a
FDA or CLIA
Identification
number?"

Selecting the
checkbox displays
FDA, and CLIA text
entry fields.

CLIA (Clinical
Accreditation Below
Text Entry The field is
Laboratory
(1)
checkbox
displayed if the
Improvement Act)
"Does the
user selects the
subject have a
checkbox for
FDA or CLIA
"Does the
identification
subject have a
number?"
FDA or CLIA
Identification
number?"

Selecting the
checkbox displays
FDA, and CLIA text
entry fields.

Type of
Affiliation

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

Accreditation Below the
(1)
checkbox "Is
the
organization
affiliated with
a health care
entity?

Drop List

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Label

PDF Name
(step)

Entity Name

Accreditation Below Type of Text
(1)
Affiliation
Entry

The field is
displayed if the
user selects the
checkbox for "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.

Country

Accreditation Below Entity
(1)
Name

The field is
displayed if the
user selects the
checkbox for "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 selected
by default.

Address

Accreditation Below Country Text Entry The field is
(1)
displayed if the
user selects the
checkbox for "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.

Location

Response Visibility Trigger
Input
Item

Drop List

Other

Label

PDF Name
(step)

Address Line 2

Accreditation Below Address Text Entry The field is
(1)
displayed if the
user selects the
checkbox for "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.

City

Accreditation Below Address Text Entry The field is
(1)
Line 2
displayed if the
user selects the
checkbox for "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.

State

Accreditation Beside City
(1)

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

Location

Response Visibility Trigger
Input
Item

Drop List

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Other

Label

PDF Name
(step)

ZIP

Description

Location

Response Visibility Trigger
Input
Item

Other

Accreditation Below City
(1)

Text Entry The field is
displayed if the
user selects the
checkbox for "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.

Accreditation Below an
action
(2)

Text
Entry

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

Accreditation Below Basis
(2)
for Action(s)

Text
Entry

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

requiring a
description

Description

State Changes
Label

PDF Name

Item
Type

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

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

License Number

Accreditation Text Entry Text entry is disabled if the user selects
the "No/ Not sure" option for "Does
the organization have a license?"

Select a Basis for
Action

Accreditation 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.