Professional Society

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Professional Society Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Date of Death

Professional Below "Is this
Society (1) person
deceased?"

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

Organization
Description

Professional Below
Society (1) Organization
Type

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

Description

Professional Beside
Text Entry The field is displayed “Description” is
Society (1) Profession or
if the user selects a displayed in place
Field of Licensure
profession or field of of “Specialty” if the
licensure that does selected profession
not have a specialty. 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

Professional Beside
Drop List
Society (1) Profession or
Field of Licensure

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

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

FEIN (Federal
Employer
Identification
Number)

Professional Below checkbox
Society (1) "Does the
subject have an
FEIN, or UPIN
identification
number?"

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

UPIN (Unique
Physician
Identification
Numbers)

Professional Below FEIN text
Society (1) entry

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

Type of
Affiliation

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

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.

Entity Name

Professional Below Type of
Society (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.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Country

Professional Beside Entity
Society (1) Name

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. United
States is the default
selection.

Address

Professional Below Country
Society (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.

Address Line 2

Professional Below Address
Society (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.

City

Professional Below Address
Society (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.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

State

Professional Beside City
Society (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?"

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

ZIP

Professional Below City
Society (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.

Description

Professional Below an action
Society (2) requiring a
description

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

Description

Professional Below Basis for
Society (2) Action(s)

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

Years

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

Months

Professional Beside Years
Society (2)

The field is displayed Selecting the radio
if the user selects “A button displays the
specific period of
text entries for
time” option for
Years, Months and
“How long will it
Days.
remain in effect?”

Text Entry The field is displayed Selecting the radio
if the user selects “A button displays the
specific period of
text entries for
time” option for
Years, Months and
“How long will it
Days.
remain in effect?”

Label

Days

PDF Name
(step)

Location

Professional Beside Months
Society (2)

Response
Input
Item

Visibility Trigger

Other

Text Entry The field is displayed Selecting the radio
if the user selects “A button displays the
specific period of
text entries for
time” option for
Years, Months and
“How long will it
Days.
remain in effect?”

State Changes
Label

PDF Name

Item Type

Trigger

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

Professional
Society

Modal

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

Select a
Profession or
Field of
Licensure

Professional
Society

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)

Professional
Society

Text Entry

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

License
Number

Professional
Society

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?"

Label

PDF Name

Item Type

Trigger

Name of
School or
Institution

Professional
Society

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

Professional
Society

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

Professional
Society

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.

Label

PDF Name

I agree to allow Professional
the NPDB to
Society
send an
electronic
report notice
to (STATE
BOARD NAME).
I attest that
this is the
correct state
board to notify
based on
where the
professional
society action
arose.

Item Type
Radio
button

Trigger
This radio button is displayed if the user selected a
profession or field of licensure and state for which a
state licensing or certification authority is registered
with the NPDB, regulates the profession for the state
and has enabled report forwarding. The registered
entity name is displayed as the STATE BOARD NAME.
The radio button is displayed above the radio button
“I attest that I will provide a copy of this report to the
appropriate state board.” This is above the final
Certification section of the form.