Document
Deferred Conviction
ICR 202610-0906-006 · OMB 0906-0081 · Object 174167200.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Deferred Conviction |
| Author | Jo Anne Wright |
| Last Modified By | Adobe Acrobat (64-bit) 26.1.21431 |
| File Modified | 2026-06-26 |
| File Created | 2026-04-23 |
| Conversion State | complete |
Extracted Text
Deferred Conviction or Pre-Trial Diversion Form and Instruction
Non-visible Questions
Label
PDF Name
(step)
Location
Date of Death
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Below "Is this
person
deceased?"
Text Entry The field is displayed
if the user selects
the "Yes" radio
button for "Is this
person deceased?"
Organization
Description
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Below
Organization
Type
Text Entry The field is displayed
if the user selects an
organization type
that requires a
description.
Description
Deferred
Conviction
or Pre-Trial
Diversion
(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
Deferred
Conviction
or Pre-Trial
Diversion
(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.
Response
Input Item
Visibility Trigger
The field is displayed
if the user selects a
profession or field of
licensure that has a
specialty.
Other
Label
PDF Name
(step)
FEIN (Federal
Employer
Identification
Number)
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Below
Text Entry
checkbox
"Does the
subject have an
FEIN, or UPIN
identification
number?"
UPIN (Unique
Physician
Identification
Numbers)
Deferred
Conviction
or Pre-Trial
Diversion
(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.
Below FEIN
text entry
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.
FDA (Federal
Deferred
Food and Drug Conviction
Administration) or Pre-Trial
Diversion
(1)
Below
checkbox
"Does the
subject have a
FDA or CLIA
identification
number?"
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.
CLIA (Clinical
Laboratory
Improvement
Act)
Below text
Text Entry
entry FDA
(Federal Food
and Drug
Administration)
Deferred
Conviction
or Pre-Trial
Diversion
(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
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Entity Name
Deferred
Conviction
or Pre-Trial
Diversion
(1)
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?”
Below Type of
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
Country
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Below Entity
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.
For an organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”
Address
Deferred
Conviction
or Pre-Trial
Diversion
(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)
Location
Address Line 2
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Below Address
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
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Below Address Text Entry For an individual
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
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Beside City
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
Deferred
Conviction
or Pre-Trial
Diversion
(1)
Below City
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
Deferred
Conviction
or Pre-Trial
Diversion
(2)
Below “Act or
Omission”
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
Deferred
Conviction
or Pre-Trial
Diversion
(2)
Below "Is the
Action on
Appeal"
Text Entry The field is displayed
if the user selects
the "Yes?" radio
button for "Is the
Action on Appeal?"
Years
Deferred
Conviction
or Pre-Trial
Diversion
(2)
Beside
Sentence or
Judgment drop
list
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.
Response
Input Item
Visibility Trigger
Other
fields are shown
Months
Deferred
Conviction
or Pre-Trial
Diversion
(2)
Beside Years
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
Deferred
Conviction
or Pre-Trial
Diversion
(2)
Beside Months
Text Entry This field is displayed If the user selects a
if this time frame is sentence or
judgment for which
applicable for the
Years, Months, and
sentence or
Days timeframe
judgment the user
applies, then these
selects.
fields are shown
Hours
Deferred
Conviction
or Pre-Trial
Diversion
(2)
Beside
Sentence or
Judgment drop
list
Text Entry 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
OMB Number:
0906-0081
Expiration
Date:
mm/dd/yyyy
Deferred
Conviction or PreTrial Diversion
Modal
When the user selects the link the modal is displayed
with the public burden statement content.
Profession or
Field of
Licensure
Deferred
Conviction or PreTrial Diversion
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)
Deferred
Conviction or PreTrial Diversion
Text Entry
Text entry is disabled until the user selects a
profession or field of licensure that allows or requires
a description.
License
Number
Deferred
Conviction or PreTrial Diversion
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?" For
organization reports, the label is “Does the
organization have a license?”
Select an Act
or Omission
Deferred
Conviction or PreTrial Diversion
Modal
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.
Item Type
Trigger