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pdf Non-visible Questions
Label
PDF Name (step)
Location
Response
Input
Item
Visibility
Trigger
Other
Date of Death
Exclusion/Debarment(1) Below "Is this
person
deceased?"
Text
Entry
The field is
displayed
if the user
selects the
"Yes" radio
button for "Is
this person
deceased?"
Organization
Description
Exclusion/Debarment(1) Below
Organization
Type
Text
Entry
The field is
displayed
if the user
selects an
organization
type that
requires a
description.
Name of
Occupation
Exclusion/Debarment(1) Beside
Profession or
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
Exclusion/Debarment(1) Beside
Profession or
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)
Exclusion/Debarment(1) Below
Text
checkbox
Entry
"Does the
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)
Exclusion/Debarment(1) Below FEIN
text entry
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.
Text
Entry
The field is
displayed in
the
organization
report form
if the user
selects the
checkbox
for "Does the
subject have a
FDA or CLIA
identification
number?"
Selecting the
checkbox displays
FDA and CLIA,
and text entry
fields.
FDA (Federal
Exclusion/Debarment(1) Below
Food and Drug
checkbox
Administration)
"Does the
subject have a
FDA or CLIA
identification
number?"
CLIA (Clinical
Laboratory
Improvement
Act)
Exclusion/Debarment(1)) Below text
Text
entry FDA
Entry
(Federal Food
and Drug
Administration)
The field is
displayed in
the
organization
report form
if the user
selects the
checkbox
for "Does the
subject have a
FDA or CLIA
identification
number?"
Selecting the
checkbox displays
FDA and CLIA,
and text entry
fields.
Type of
Affiliation
Exclusion/Debarment(1) Below "Is the
Drop List
practitioner
affiliated with a
health care
entity?"
checkbox
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
Exclusion/Debarment(1) Below Type of
Affiliation
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.
Text
Entry
Country
Exclusion/Debarment(1) Below "Is the
Drop List
practitioner
affiliated with a
health care
entity?"
checkbox
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
Exclusion/Debarment(1) Below Country
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
Exclusion/Debarment(1) Below Address
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
Exclusion/Debarment(1) Below Address Text
Line 2
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.
State
Exclusion/Debarment(1) Below City
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
Exclusion/Debarment(1) Below State
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
Exclusion/Debarment (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
Exclusion/Debarment (2) Below Basis of
Action(s)
Text
Entry
The field is
displayed
if the user
selects a basis
of action that
requires a
description.
Period of time
number
Exclusion/Debarment (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
type
Exclusion/Debarment (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.
Date of Appeal Exclusion/Debarment (2) Below Is the
action on
appeal?
Text
Entry
The field is
displayed if
the user
selects Yes
option for “Is
the action on
appeal?”
State Changes
Label
PDF Name
Item Type
Trigger
Public Burden
Statement
Exclusion/Debarment Modal
When the user selects the Public Burden Statement
link the modal is displayed.
Select a
Profession or
Field of
Licensure
Exclusion/Debarment 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
Exclusion/Debarment Text Entry
Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.
License
Number
Exclusion/Debarment 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
Exclusion/Debarment 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 | 2017-09-25 |