Government Administrative

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Government Administrative Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Government Below "Is this
Administrative person
deceased?"
(1)

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

Organization
Description

Government Below
Administrative Organization
Type
(1)

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

Description

Government Beside
Administrative Profession or
(1)
Field of
Licensure

Text entry The field is
“Description” is
displayed if the user displayed in place
selects a profession of “Specialty” if the
or field of licensure selected profession
that does not have a or field of licensure
specialty
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

Government Beside
Administrative Profession or
(1)
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.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

FEIN (Federal
Employer
Identification
Number)

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

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)

Government Below FEIN
Administrative text entry
(1)

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.

FDA (Federal
Government Below
Food and Drug Administrative checkbox
Administration) (1)
"Does the
subject have a
FDA or CLIA
identification
number?"

CLIA (Clinical
Laboratory
Improvement
Act)

Text Entry The field is
Selecting the
displayed in the
checkbox displays
organization report FDA and CLIA, and
form if the user
text entry fields.
selects the checkbox
for "Does the
subject have a FDA
or CLIA
identification
number?"

Government Below text
Text Entry
Administrative entry FDA
(1)
(Federal Food
and Drug
Administration)

The field is
Selecting the
displayed in the
checkbox displays
organization report FDA and CLIA, and
form if the user
text entry fields.
selects the checkbox
for "Does the
subject have a FDA
or CLIA
identification
number?"

Label

PDF Name
(step)

Location

Response
Input Item

Type of
Affiliation

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

Entity Name

Government Below Type of
Administrative Affiliation
(1)

Visibility Trigger

Other

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
Address Line 2,
affiliated with a
health care entity?" 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
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
affiliated with a
Address Line 2,
health care entity?" 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?”

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Country

Government Below Entity
Administrative Name
(1)

Drop List

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
Address Line 2,
affiliated with a
health care entity?" City, State, and ZIP
entries. United
States is the
For an
default selection.
organizational
report, the field is
displayed if the user
selects the checkbox
“Is the organization
affiliated with a
health care entity?”

Address

Government Below Country
Administrative
(1)

Text Entry For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
affiliated with a
Address Line 2,
health care entity?" 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?”

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Address Line 2

Government Below Address
Administrative
(1)

Text Entry For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
Address Line 2,
affiliated with a
health care entity?" 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?”

City

Government Below Address Text Entry For an individual
Selecting the
Administrative Line 2
report, the field is
checkbox displays
(1)
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
affiliated with a
Address Line 2,
health care entity?" 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?”

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

State

Government Beside City
Administrative
(1)

Drop List

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
Address Line 2,
affiliated with a
health care entity?" 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

Government Below City
Administrative
(1)

Text Entry For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the checkbox Entity Name,
"Is the practitioner Country, Address,
affiliated with a
Address Line 2,
health care entity?" 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

Government Below an
Administrative action
(2)
requiring a
description

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

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Description

Government Below Basis for Text Entry The field is
Administrative Action(s)
displayed if the user
selects a basis for
(2)
action that requires
a description.

Years

Government Below the
Text Entry
Administrative radio button “A
specific period
(2)
of time”

Months

Government Beside Years
Administrative
(2)

Days

Other

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
text entries for
Years, Months and
Days.

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
text entries for
Years, Months and
Days.

Government Beside Months Text Entry The field is
Administrative
displayed if the user
(2)
selects “A specific
period of time”
option for “How
long will it remain in
effect?”

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

Is
Government Below “How
reinstatement Administrative long will it
automatic after (2)
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?”

Date of Appeal Government Below Is the
Administrative action on
(2)
appeal?

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

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

State Changes
Label

PDF Name

Item Type

Trigger

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

Government
Administrative

Modal

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

Select a
Profession or
Field of
Licensure

Government
Administrative

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)

Government
Administrative

Text Entry

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

License
Number

Government
Administrative

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?"

Name of
School or
Institution

Government
Administrative

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 carerelated profession redisplays both fields

Label

PDF Name

Item Type

Trigger

Completion
Year

Government
Administrative

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 carerelated profession redisplays both fields

Select up to 5
actions

Government
Administrative

Multi select
Drop List

The list of actions displayed for selection is dynamic,
depending on the user’s selection for the radio
buttons for “Select a type of action”
• This action is related to a certification
agreements or contracts for participation in a
federal or state health care program,
including state nurse aide registry findings.
• This is an “other adjudicated action or
decision.”

Select a Basis
for Action

Government
Administrative

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.