Form 19 Self-Query on an Individual

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms

19 SelfQueryIndividual

Self-Query on an Individual

OMB: 0915-0126

Document [pdf]
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Non-visible Questions
Label
State where you currently
work or last worked

Completion Date
DEA (Drug Enforcement
Agency)
FEIN (Federal Employer
Identification Number)
FDA (Food and Drug
Administration)
Experian questions

PDF Name
Location
(step)
SQInd (1)
Below “Do you have a license
for your selected profession
or field of licensure?”

Response
Input Item
Text box

SQInd (1)
SQOrg (1)
SQInd (1)
SQOrg (1)
SQInd (1)
SQOrg (1)
SQInd (1)
SQOrg (1)
SQInd (4)

To the right of “Completed?”

Text box

Below “NPI”

Text box

If user selects "No" or "Not
sure" option in response to "Do
you have a license for your
selected profession or field of
licensure?”
If user selects "Yes" option in
response to "Completed?"
If user selects DEA checkbox

Below “DEA”

Text box

If user selects FEIN checkbox

Below “FEIN”

Text box

If user selects FDA checkbox

“Identity Verification” tab

Radio
button

State Changes
Label
Profession or Field of
Licensure Modal

PDF Name
SQProfession

Item Type
Modal

Password Rules

SQPassword

Info box

Visibility Trigger

Other

"yyyy" hint text in text box

Question and answer content
determined by Experian. User will
be shown four questions, at least
one of which contains financial
information. The questions are
customized based on the user’s
information. The user may be shown
questions other than those pictured
in the PDF.

Visibility Trigger
When the “Profession or Field of Licensure” text box is selected
the Profession or Field of Licensure modal shown in the
SQFormProfession PDF appears.
When "view rules" is clicked, or when the “Password” text box is
selected, the Password Rules info box shown in the
SQFormPassword PDF appears.


File Typeapplication/pdf
File Modified2014-11-24
File Created2014-11-24

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