Exclusion or Debarment

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Exclusion or Debarment Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Date of Death

Exclusion or
Debarment(1)

Below "Is this
person
deceased?"

Organization
Description

Description

Response
Input
Item

Visibility Trigger

Text
Entry

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

Exclusion or
Debarment(1)

Below
Text
Organization Type Entry

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

Exclusion or
Debarment(1)

Beside Profession
or Field of
Licensure

The field is
displayed if the
user selects a
profession or field
of licensure that
does not have a
specialty.

Text
Entry

Other

“Description” is
displayed in place
of “Specialty” if
the selected
profession or
field of licensure
that 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)”

Label

PDF Name
(step)

Location

Specialty

Exclusion or
Debarment(1)

Beside Profession
or Field of
Licensure

Drop List 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.

FEIN (Federal
Employer
Identification
Number)

Exclusion or
Debarment(1)

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

Text
Entry

The field is
displayed in the
individual 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)

Exclusion or
Debarment(1)

Below FEIN text
entry

Text
Entry

The field is
displayed in the
individual 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 checkbox
Text
"Does the subject Entry
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.

FDA (Federal
Exclusion or
Food and Drug Debarment(1)
Administration)

Response
Input
Item

Visibility Trigger

Other

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

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.

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.

CLIA (Clinical
Laboratory
Improvement
Act)

Exclusion or
Below text entry
Text
Debarment(1)) FDA (Federal Food Entry
and Drug
Administration)

Type of
Affiliation

Exclusion or
Debarment(1)

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

Label

PDF Name
(step)

Location

Entity Name

Exclusion or
Debarment(1)

Below Type of
Affiliation

Response
Input
Item

Visibility Trigger

Other

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.

For an
organizational
report, the field is
displayed if the
user selects the
checkbox “Is the
organization
affiliated with a
health care
entity?”
Country

Exclusion or
Debarment(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?"
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. United
States is the
default selection.

Label

Address

PDF Name
(step)

Location

Exclusion or
Debarment(1)

Below Country

Response
Input
Item

Visibility Trigger

Other

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.

For an
organizational
report, the field is
displayed if the
user selects the
checkbox “Is the
organization
affiliated with a
health care
entity?”
Address Line 2

Exclusion or
Debarment(1)

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?”

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

Label

City

PDF Name
(step)

Location

Exclusion or
Debarment(1)

Below Address
Line 2

Response
Input
Item

Visibility Trigger

Other

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.

For an
organizational
report, the field is
displayed if the
user selects the
checkbox “Is the
organization
affiliated with a
health care
entity?”
State

Exclusion or
Debarment(1)

Beside City

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?"
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

ZIP

PDF Name
(step)
Exclusion or
Debarment(1)

Location

Below City

Response
Input
Item

Visibility Trigger

Other

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.

For an
organizational
report, the field is
displayed if the
user selects the
checkbox “Is the
organization
affiliated with a
health care
entity?”
Description

Exclusion or
Below Basis for
Debarment (2) Action(s)

Text
Entry

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

Years

Exclusion or
Below the radio
Debarment (2) button “A specific
period of time”

Text
Entry

The field is
displayed if the
user selects “A
specific period of
time” option for
“How long will it
remain in effect?”

Selecting the
radio button
displays the
entries for Years,
Months, and
Days.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Months

Exclusion or
Beside Years
Debarment (2)

Text
Entry

The field is
displayed if the
user selects “A
specific period of
time” option for
“How long will it
remain in effect?”

Selecting the
radio button
displays the
entries for Years,
Months, and
Days.

Days

Exclusion or
Beside Months
Debarment (2)

Text
Entry

The field is
displayed if the
user selects “A
specific period of
time” option for
“How long will it
remain in effect?”

Selecting the
radio button
displays the
entries for Years,
Months, and
Days.

Is reinstatement Exclusion or
Below “How long
automatic after Debarment (2) will it remain in
this period of
effect?”
time?

Radio
Buttons

The fields are
displayed if the
user selects “A
specific period of
time” for “How
long will it remain
in effect?”

Available options
are “No,” “Yes”
and “Yes with
conditions
(Requires a
Revision to
Action report
when status
changes)

Date of Appeal

Text
Entry

The field is
displayed if the
user selects Yes
option for “Is the
action on
appeal?”

Exclusion or
Below Is the
Debarment (2) action on appeal?

State Changes
Label

PDF Name

Item Type

Trigger

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

Exclusion or
Debarment

Modal

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

Select a
Profession or
Field of
Licensure

Exclusion or
Debarment

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.

Name of
School or
Institution

Exclusion or
Debarment

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

Exclusion or
Debarment

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

Description
(Optional)

Exclusion or
Debarment

Text Entry

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

Label

PDF Name

Item Type

Trigger

License
Number

Exclusion or
Debarment

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?"

Select a Basis
for Action

Exclusion or
Debarment

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.