One-Time Query for an Individual

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One-Time Query for an Individual Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response Visibility
Input
Trigger
Item

Organization
Description

One-Time
Query for an
Individual
(1)

Below
Organization
Type

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

Description

One-Time
Beside
Text entry The field is
“Description is
Query for an Profession or
displayed
displayed in place
Individual (1) Field of
if the user
of “Specialty” if the
Licensure
selects a
profession or field
profession or of licensure does
field of
not have a
licensure that specialty. The label
is “Description” if
does not
the selected
have a
profession or field
specialty
of licensure
requires a
description.
Otherwise, the
label is
“Description
(Optional)”

Specialty

One-Time
Beside
Drop List
Query for an Profession or
Individual (1) Field of
Licensure

Other

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

Label

PDF Name
(step)

FEIN (Federal
Employer
Identification
Number)

One-Time
Below
Text Entry The field is
Query for an checkbox
displayed if
Individual (1) "Does the
the user
subject have
selects the
an FEIN, or
checkbox
UPIN
for "Does
identification
the subject
number?"
have an FEIN,
or UPIN
identification
number?"

Selecting the
checkbox displays
FEIN and UPIN text
entry fields.

UPIN (Unique
Physician
Identification
Numbers)

One-Time
Below FEIN
Query for an text entry
Individual (1)

Text Entry The field is
displayed 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.

Entity
Selection

One-Time
After step 1
Query for an Subject
Individual (2) Information

Check
boxes

Location

Response Visibility
Input
Trigger
Item

Other

The Entity
All entities are
Selection
listed for which the
section is
user is authorized
only
to query.
displayed if
the user is
authorized to
act as an
agent to
query on
behalf of
other
entities.

State Changes
Label

PDF Name

Item Type

Trigger

OMB
Query Input - Modal
Number:
Individual
0906-0081
Expiration
Date:
mm/dd/yyyy

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

Subjects
Available

Query Input - Table
Individual

When the user selects the option to enroll from
their subject database, the summary table of
the subjects with previously saved subject
information is displayed. The user select one or
more names from the table, then select
continue to enter payment information.

Select a
Profession
or Field of
Licensure

Query Input - Modal
Individual

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)

Query Input - Text Entry
Individual

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

License
Number

Query Input - Text Entry
Individual

Text entry is disabled if the user selects the "No/
Not sure" option for "Does the subject have a
license for your selected profession or field of
licensure?"