Civil Judgment

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Civil Judgment Form and Instruction

Non-visible Questions
Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Civil
Below "Is this
Judgment person
(1)
deceased?"

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

Organization
Description

Civil
Below
Judgment Organization
(1)
Type

Text Entry

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

Description

Civil
Beside Profession Text Entry
Judgment or Field of
(1)
Licensure

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

Civil
Beside Profession Drop List
Judgment or Field of
(1)
Licensure

The field is displayed
if the user selects a
profession or field of
licensure that has a
specialty.

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

Label

PDF
Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

FEIN (Federal
Employer
Identification
Number)

Civil
Below checkbox Text Entry
Judgment "Does the subject
(1)
have an FEIN, or
UPIN
identification
number?"

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.

UPIN (Unique
Physician
Identification
Numbers)

Civil
Below FEIN text
Judgment entry
(1)

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
Civil
Below checkbox Text Entry
Food and Drug Judgment "Does the subject
Administration) (1)
have a FDA or
CLIA
identification
number?"

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)

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.

Civil
Below text entry
Judgment FDA (Federal
(1)
Food and Drug
Administration)

Text Entry

Label

Type of
Affiliation

Entity Name

PDF
Name
(step)

Location

Response
Input Item

Civil
Below the
Drop List
Judgment checkbox "Is the
(1)
practitioner
affiliated with a
health care
entity?" or ”Is the
organization
affiliated with a
health care
entity?”

Civil
Below Type of
Judgment Affiliation
(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

Civil
Below Entity
Judgment Name
(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

Civil
Below Country
Judgment
(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?”

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

Label

Address Line 2

PDF
Name
(step)

Location

Civil
Below Address
Judgment
(1)

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

Civil
Below Address
Judgment Line 2
(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?”

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

Civil
Beside City
Judgment
(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

Civil
Below City
Judgment
(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

Civil
Below “Act or
Judgment Omission”
(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

Response
Input Item

Date of Appeal

Civil
Below "Is the
Judgment Action on
(2)
Appeal"

Years

Civil
Beside Sentence Text Entry
Judgment or Judgment drop
(2)
list

Visibility Trigger

Other

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

Civil
Beside Years
Judgment
(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

Civil
Beside Months
Judgment
(2)

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

Civil
Beside Sentence Text Entry
Judgment or Judgment drop
(2)
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

Civil Judgment

Modal

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

Profession or
Field of
Licensure

Civil Judgment

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)

Civil Judgment

Text Entry

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

License
Number

Civil Judgment

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

Civil Judgment

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.