Self Query on an Individual

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Self Query on an Individual Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Description

Self-Query
on an
Individual
(Personal
Profile)

Beside
Profession or
Field of
Licensure

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

Self-Query
on an
Individual
(Personal
Profile)

Beside
Profession or
Field of
Licensure

Text Entry

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

DEA (Drug
Enforcement
Agency)

Self-Query
on an
Individual
(Personal
Profile)

Below
checkbox "Do
you have a
DEA, FEIN, or
UPIN
identification
number?"

Text Entry

Field is displayed if
user selects the
checkbox for "Do
you have a DEA,
FEIN, or UPIN
identification
number?"

FEIN (Federal
Employer
Identification
Number)

Self-Query
on an
Individual
(Personal
Profile)

Below DEA
text entry.

Text Entry

The field is
Selecting the
displayed if the user checkbox displays
selects the
DEA, FEIN and UPIN
checkbox for "Do
text entry fields.
you have a DEA,
FEIN, or UPIN
identification
number?"

Response
Input Item

Visibility Trigger

Other

Selecting the
checkbox displays
DEA, FEIN and UPIN
text entry fields.

Label

PDF Name
(step)

Location

Response
Input Item

UPIN (Unique
Physician
Identification
Numbers)

Self-Query
on an
Individual
(Personal
Profile)

Below FEIN
text entry

Text Entry

Send text
message
notifications
(Carrier’s fees
may apply

Self-Query
on an
Individual
(Personal
Profile)

Below This is a Checkbox
mobile phone

This field is
Selecting the
displayed if the user checkbox displays
selects the This is a the Send text
mobile phone
message
checkbox
notifications
checkbox

Address

Self-Query
on an
Individual
(Your
Order)

Below "Use
my home
address" and
"Delivery to a
different
address"
options for
Delivery
Address

Text Entry

The field is
Selecting "Deliver to
displayed if the user a different address"
selects the radio
displays Address,
button "Deliver to a Address Line 2, City,
different address" State and ZIP
entries.

Address Line 2 Self-Query
on an
Individual
(Your
Order))

Below Address Text Entry

The field is
Selecting "Deliver to
displayed if the user a different address"
selects the radio
displays Address,
button "Deliver to a Address Line 2, City,
different address" State and ZIP
entries.

City

Below Address Text Entry
Line 2

The field is
Selecting "Deliver to
displayed if the user a different address"
selects the radio
displays Address,
button " Use a
Address Line 2, City,
different address" State and ZIP
entries.

Self-Query
on an
Individual
(Your
Order)

Visibility Trigger

Other

The field is
Selecting the
displayed if the user checkbox displays
selects the
DEA, FEIN and UPIN
checkbox for "Do
text entry fields.
you have a DEA,
FEIN, or UPIN
identification
number?"

Label

PDF Name
(step)

Location

State

Self-Query
on an
Individual
(Your
Order)

Beside City

Drop List

The field is
Selecting "Deliver to
displayed if the user a different address"
selects the radio
displays Address,
button " Use a
Address Line 2, City,
different address" State and ZIP
entries.

ZIP

Self-Query
on an
Individual
(Your
Order)

Below State

Text Entry

The field is
Selecting "Deliver to
displayed if the user a different address"
selects the radio
displays Address,
button " Use a
Address Line 2, City,
different address" State and ZIP
entries.

Card Number

Self-Query
on an
Individual
(Your
Order)

Below "Use
Text Entry
my saved
card" and
"Use a
different card"
options for
Enter your
payment
information

The field is
Selecting "Use a
displayed if the user different card"
selects the radio
displays Card
button "Use a
Number, Expiration
different card"
Date (Month/Year),
Name of Cardholder
entries.

Expiration
Date (Month)

Self-Query
on an
Individual
(Your
Order)

Beside Card
Number

Drop List

The field is
Selecting "Use a
displayed if the user different card"
selects the radio
displays Card
button "Use a
Number, Expiration
different card"
Date (Month/Year),
Name of Cardholder
entries.

Expiration
Date (Year)

Self-Query
on an
Individual
(Your
Order)

Beside Year
drop list for
Expiration
Date

Drop List

The field is
Selecting "Use a
displayed if the user different card"
selects the radio
displays Card
button "Use a
Number, Expiration
different card"
Date (Month/Year),
Name of Cardholder
entries.

Response
Input Item

Visibility Trigger

Other

Label

PDF Name
(step)

Location

Response
Input Item

Name of
Cardholder

Self-Query
on an
Individual
(Your
Order)

Below Card
Number

Text Entry

The field is
Selecting "Use a
displayed if the user different card"
selects the radio
displays Card
button "Use a
Number, Expiration
different card"
Date (Month/Year),
Name of Cardholder
entries.

Country

Self-Query
on an
Individual
(Your
Order)

Below "Use
Drop List
the address I
entered" and
"Use a
different
address"
options for
Billing Address

The field is
Selecting "Use a
displayed if the user different address"
selects the radio
displays Country,
button "Use a
Address, Address
different address" Line 2, City, State
and ZIP
entries. United
States is the default
selection.

Address

Self-Query
on an
Individual
(Your
Order)

Below Country Text Entry

The field is
Selecting " Use a
displayed if the user different address"
selects the radio
displays Country,
button " Use a
Address, Address
different address" Line 2, City, State
and ZIP entries.

Address Line 2 Self-Query
on an
Individual
(Your
Order))

Below Address Text Entry

The field is
Selecting " Use a
displayed if the user different address"
selects the radio
displays Country,
button " Use a
Address, Address
different address" Line 2, City, State
and ZIP entries.

City

Below Address Text Entry
Line 2

The field is
Selecting " Use a
displayed if the user different address"
selects the radio
displays Country,
button " Use a
Address, Address
different address" Line 2, City, State
and ZIP entries.

Self-Query
on an
Individual
(Your
Order)

Visibility Trigger

Other

Label

PDF Name
(step)

Location

State

Self-Query
on an
Individual
(Your
Order)

Beside City

Drop List

The field is
Selecting " Use a
displayed if the user different address"
selects the radio
displays Country,
button " Use a
Address, Address
different address" Line 2, City, State
and ZIP entries.

ZIP

Self-Query
on an
Individual
(Your
Order)

Below State

Text Entry

The field is
Selecting " Use a
displayed if the user different address"
selects the radio
displays Country,
button " Use a
Address, Address
different address" Line 2, City, State
and ZIP entries.

Response
Input Item

Visibility Trigger

Other

State Changes
Label

PDF Name

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

Self-Query on
an Individual

Modal

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

Select an
Occupation or
Field of
Licensure

Self-Query on
an Individual

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)

Self-Query on
an Individual

Text Entry

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

License Number

Self-Query on
an Individual

Text Entry

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

Item Type

Trigger