Injuction

Status: Original and derived artifacts are available for this document.

Download: pdf

Injunction Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Date of Death

Injunction
(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

Injunction
(1)

Below
Organization
Type

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

Description

Injunction
(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

Injunction
(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)

Injunction
(1)

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

UPIN (Unique
Physician
Identification
Numbers)

Injunction
(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
Injunction
Food and Drug (1)
Administration)

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)

Injunction
(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

Injunction
(1)

Entity Name

Injunction
(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 "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

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 “Is the
organization
affiliated with a
health care entity?”

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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(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

Injunction
(2)

Beside Months

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

Hours

Injunction
(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

Item Type

Trigger

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

Injunction

Modal

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

Profession or
Field of
Licensure

Injunction

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)

Injunction

Text Entry

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

License
Number

Injunction

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

Injunction

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.