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pdf Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Other
Date of Death Title IV
Below "Is this
Clinical
person
Privileges (1) deceased?"
Text Entry
The field is displayed
if the user selects the
"Yes" radio button for
"Is this person
deceased?"
Organization
Description
Title IV
Below
Clinical
Organization
Privileges (1) Type
Text Entry
The field is displayed
if the user selects an
organization type that
requires a description.
Name of
Occupation
Title IV
Beside
Clinical
Profession or
Privileges (1) Field of
Licensure
Text entry
The field is displayed
if the user selects a
profession or field of
licensure that requires
a description.
“Specialty” is
displayed in place of
“Name of
Occupation” if the
selected profession
or field of
licensure requires
specialty
information.
Specialty
Title IV
Beside
Clinical
Profession or
Privileges (1) Field of
Licensure
Drop List
The field is displayed
if the user selects a
profession or field of
licensure that requires
information for
specialty.
“Name of
Occupation” is
displayed in place of
“Specialty” if the
selected profession
or field of licensure
does not require
information for a
specialty.
FEIN (Federal
Employer
Identification
Number)
Title IV
Below
Clinical
checkbox
Privileges (1) "Does the
subject have
an FEIN, or
UPIN
identification
number?"
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.
UPIN (Unique Title IV
Below FEIN
Physician
Clinical
text entry
Identification Privileges (1)
Numbers)
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.
Type of
Affiliation
Title IV
Below "Is the
Clinical
practitioner
Privileges (1) affiliated with
a health care
entity?"
checkbox
Drop List
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Entity Name
Title IV
Below Type of
Clinical
Affiliation
Privileges (1)
Text Entry
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.
Country
Title IV
Below "Is the
Clinical
practitioner
Privileges (1) affiliated with
a health care
entity?"
checkbox
Drop List
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
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.
Address
Title IV
Below Country
Clinical
Privileges (1)
Text Entry
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP entries.
Address Line
2
Title IV
Below Address
Clinical
Privileges (1)
Text Entry
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP entries.
City
Title IV
Below Address Text Entry
Clinical
Line 2
Privileges (1)
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP entries.
State
Title IV
Below City
Clinical
Privileges (1)
Drop List
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP entries.
ZIP
Title IV
Below State
Clinical
Privileges (1)
Text Entry
The field is displayed
if the user selects the
"Is the practitioner
affiliated with a health
care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP entries.
Description
Title IV
Clinical
Privilege (2)
Below an
action that
requires a
description
Text Entry
The field is displayed
if the user selects an
action that requires a
description.
Description
Title IV
Clinical
Privilege (2)
Below Basis of Text Entry
Action(s)
The field is displayed
if the user selects a
basis of action that
requires a description.
Period of time Title IV
number
Clinical
Privilege (2)
Below “How
long will it
remain in
effect?”
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
number text entry
and type of time
period drop list.
Period of time Title IV
type
Clinical
Privilege (2)
Below “How
long will it
remain in
effect?”
Drop List
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
number text entry
and type of time
period drop list.
State Changes
Label
PDF Name
Item Type
Trigger
Public Burden
Statement
Title IV Clinical
Privileges
Modal
When the user selects the Public Burden Statement
link the modal is displayed.
Select a
Profession or
Field of
Licensure
Title IV Clinical
Privileges
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
Occupation
Title IV Clinical
Privileges
Text Entry
Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.
License
Number
Title IV Clinical
Privileges
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
Title IV Clinical
Privileges
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.
| File Type | application/pdf |
| File Modified | 2017-11-09 |
| File Created | 2017-09-27 |