Form 9 Criminal Conviction (Guilty Plea or Trial)

Criminal Conviction (Guilty Plea or Trial) Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Criminal
Below "Is this
Conviction person
(Guilty Plea deceased?"
or Trial) (1)

Text Entry The field is displayed
if the user selects
the "Yes" radio
button for "Is this
person deceased?"

Organization
Description

Criminal
Below
Conviction Organization
(Guilty Plea Type
or Trial) (1)

Text Entry

Specialty

Criminal
Conviction
(Guilty Plea
or Trial) (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 “Description” if
the selected
profession or field
of
licensure requires
specialty
information.

Description

Criminal
Conviction
(Guilty Plea
or Trial) (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.

“Description” 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)

Criminal
Conviction
(Guilty Plea
or Trial) (1)

Below
Text Entry
checkbox
"Does the
subject have an
FEIN, or UPIN
identification
number?"

The field is displayed
in the individual
report 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.

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

Label
UPIN (Unique
Physician
Identification
Numbers)

PDF Name
(step)

Location

Criminal
Below FEIN
Conviction text entry
(Guilty Plea
or Trial) (1)

Response
Input Item

Visibility Trigger

Other

Text Entry

The field is displayed
in the individual
report 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.

FDA (Federal
Criminal
Food and Drug Conviction
Administration) (Guilty Plea
or Trial) (1)

Below
checkbox
"Does the
subject have a
FDA or CLIA
identification
number?"

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.

CLIA (Clinical
Laboratory
Improvement
Act)

Criminal
Conviction
(Guilty Plea
or Trial) (1)

Below text
Text Entry
entry FDA
(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

Criminal
Conviction
(Guilty Plea
or Trial) (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.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Text Entry The field is displayed
if the user selects
the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.

Other

Entity Name

Criminal
Below Type of
Conviction Affiliation
(Guilty Plea
or Trial) (1)

Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries.

Country

Criminal
Conviction
(Guilty Plea
or Trial) (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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Address

Criminal
Conviction
(Guilty Plea
or Trial) (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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Label

PDF Name
(step)

Location

Response
Input Item

Address Line 2

Criminal
Conviction
(Guilty Plea
or Trial) (1)

City

Criminal
Below Address Text Entry
Conviction Line 2
(Guilty Plea
or Trial) (1)

Visibility Trigger

Below Address Text Entry The field is displayed
if the user selects
the "Is the
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.

Other
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2, City,
State and ZIP
entries. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

State

Criminal
Below City
Conviction
(Guilty Plea
or Trial) (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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

ZIP

Criminal
Below State
Conviction
(Guilty Plea
or Trial) (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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Description

Criminal
Below “Act or
Conviction Omission”
(Guilty Plea
or Trial) (2)

Text Entry

Date of Appeal

Criminal
Below "Is the
Conviction Action on
(Guilty Plea Appeal"
or Trial) (2)

Text Entry The field is displayed
if the user selects
the "Yes?" radio
button for "Is the
Action on Appeal?"

The field is displayed
if the user selects an
act or omission that
requires a
description.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Years

Criminal
Conviction
(Guilty Plea
or Trial) (2)

Beside
Sentence of
Judgment drop
list

Drop List

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
does not apply,
then Years, Months
and Days drop lists
are displayed.

Months

Criminal
Beside Years
Conviction
(Guilty Plea
or Trial) (2)

Drop List

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
does not apply,
then Years, Months
and Days drop lists
are displayed.

Days

Criminal
Beside Months
Conviction
(Guilty Plea
or Trial) (2)

Drop List

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
does not apply,
then Years, Months
and Days drop lists
are displayed.

Hours

Criminal
Beside Months
Conviction
(Guilty Plea
or Trial) (2)

Drop List

This field is displayed
if a time frame is
applicable for the
sentence the user
selects.

If the user selects a
sentence in which
an hours timeframe
applies, then an
Hours drop list is
displayed.

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy

Criminal Conviction Modal
(Guilty Plea or
Trial)

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

Profession or
Field of
Licensure

Criminal Conviction Modal
(Guilty Plea or
Trial)

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.

Other Name
Criminal Conviction Text Entry
for Occupation (Guilty Plea or
Trial)

Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.

License
Number

Criminal Conviction Text Entry
(Guilty Plea or
Trial)

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?" For
organization reports, the label is “Does the
organization have a license?”

Select an Act
or Omission

Criminal Conviction Modal
(Guilty Plea or
Trial)

When the user sets focus on the Act or Omission 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 act
or select an act from the list without searching. The
modal is hidden once the user selects an act from the
list. The user's selection populates the Act or
Omission text entry.