Criminal Conviction

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Criminal Conviction Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Criminal
Below "Is this
Conviction person
(Guilty Plea deceased?"
or Trial) (1)

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

Organization
Description

Criminal
Below
Conviction Organization
(Guilty Plea Type
or Trial) (1)

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

Description

Criminal
Conviction
(Guilty Plea
or Trial) (1)

Beside
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

Criminal
Conviction
(Guilty Plea
or Trial) (1)

Beside
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)

FEIN (Federal
Employer
Identification
Number)

Criminal
Conviction
(Guilty Plea
or Trial) (1)

UPIN (Unique
Physician
Identification
Numbers)

Criminal
Below FEIN
Conviction text entry
(Guilty Plea
or Trial) (1)

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.

Below
Text Entry
checkbox
"Does the
subject have an
FEIN, or UPIN
identification
number?"

FDA (Federal
Criminal
Food and Drug Conviction
Administration) (Guilty Plea
or Trial) (1)

Below
checkbox
"Does the
subject have a
FDA or CLIA
identification
number?"

CLIA (Clinical
Laboratory
Improvement
Act)

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

Criminal
Conviction
(Guilty Plea
or Trial) (1)

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

PDF Name
(step)

Type of
Affiliation

Criminal
Conviction
(Guilty Plea
or Trial) (1)

Entity Name

Location

Response
Input Item

Below the
Drop List
checkbox "Is
the
practitioner
affiliated with a
health care
entity?" or ”Is
the
organization
affiliated with a
health care
entity?”

Criminal
Below Type of
Conviction Affiliation
(Guilty Plea
or Trial) (1)

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
Country

PDF Name
(step)

Location

Criminal
Below Entity
Conviction Name
(Guilty Plea
or Trial) (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?”
Address

Criminal
Conviction
(Guilty Plea
or Trial) (1)

Below Country 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)

Address Line 2

Criminal
Conviction
(Guilty Plea
or Trial) (1)

Location

Response
Input Item

Visibility Trigger

Below Address 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

Criminal
Below Address Text Entry
Conviction Line 2
(Guilty Plea
or Trial) (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?”

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

Criminal
Beside City
Conviction
(Guilty Plea
or Trial) (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

Criminal
Below City
Conviction
(Guilty Plea
or Trial) (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?”

Description

Criminal
Below “Act or
Conviction Omission”
(Guilty Plea
or Trial) (2)

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

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

Label

PDF Name
(step)

Location

Date of Appeal

Criminal
Below "Is the
Conviction Action on
(Guilty Plea Appeal"
or Trial) (2)

Years

Criminal
Conviction
(Guilty Plea
or Trial) (2)

Response
Input Item

Visibility Trigger

Other

Text Entry The field is displayed
if the user selects
the "Yes?" radio
button for "Is the
Action on Appeal?"

Beside
Text Entry
Sentence or
Judgment drop
list

This field is displayed If the user selects a
if this time frame is sentence or
judgment in which
applicable for the
Years, Months, and
sentence or
Days timeframe
judgment the user
applies, then these
selects.
fields are shown

Months

Criminal
Beside Years
Conviction
(Guilty Plea
or Trial) (2)

Text Entry This field is displayed If the user selects a
if this time frame is sentence or
judgment in which
applicable for the
Years, Months, and
sentence or
Days timeframe
judgment the user
applies, then these
selects.
fields are shown

Days

Criminal
Beside Months Text Entry
Conviction
(Guilty Plea
or Trial) (2)

This field is displayed If the user selects a
if this time frame is sentence or
judgment in which
applicable for the
Years, Months, and
sentence or
Days timeframe
judgment the user
applies, then these
selects.
fields are shown

Hours

Criminal
Conviction
(Guilty Plea
or Trial) (2)

Beside
Text Entry
Sentence or
Judgment drop
list

This field is displayed This field is
if this time frame is displayed if the user
applicable for the
selects a sentence
sentence or
or judgment for
judgment the user
which an Hours
selects.
timeframe applies.

State Changes
Label

PDF Name

Item Type

Trigger

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

Criminal Conviction Modal
(Guilty Plea or
Trial)

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

Profession or
Field of
Licensure

Criminal Conviction Modal
(Guilty Plea or
Trial)

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)

Criminal Conviction Text Entry
(Guilty Plea or
Trial)

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

License
Number

Criminal Conviction Text Entry
(Guilty Plea or
Trial)

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?" For
organization reports, the label is “Does the
organization have a license?”

Select an Act
or Omission

Criminal Conviction Modal
(Guilty Plea or
Trial)

When the user sets focus on the Act or Omission 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 act
or select an act from the list without searching. The
modal is hidden once the user selects an act from the
list. The user's selection populates the Act or
Omission text entry.