Form 6 Accreditation

Accreditation Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Organization
Description

Accreditation Below
Text Entry
(1)
Organization
Type

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

FDA (Federal
Food and Drug
Administration)

Accreditation Below
Drop List
(1)
checkbox
"Does the
subject have
a FDA or
CLIA
identificatio
n number?"

The field is
displayed if the
user selects the
checkbox for
"Does the
subject have a
FDA or CLIA
Identification
number?"

Selecting the
checkbox displays
FDA, and CLIA text
entry fields.

CLIA (Clinical
Accreditation Below
Text Entry
Laboratory
(1)
checkbox
Improvement Act)
"Does the
subject have
a FDA or
CLIA
identificatio
n number?"

The field is
displayed if the
user selects the
checkbox for
"Does the
subject have a
FDA or CLIA
Identification
number?"

Selecting the
checkbox displays
FDA, and CLIA text
entry fields.

Type of
Affiliation

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting ""Is the
organization
affiliated with a
health care
entity?" displays
Type of Affiliation,
Entity
Name, Address,
Address Line 2,
City, State and ZIP
entries.

Accreditation Below the
Drop List
(1)
checkbox "Is
the
organization
affiliated
with a
health care
entity?

Visibility Trigger

Other

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Entity Name

Accreditation Below the
(1)
checkbox "Is
the
organization
affiliated
with a
health care
entity?

Text Entry

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting ""Is the
organization
affiliated with a
health care
entity?" displays
Type of Affiliation,
Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP entries.

Country

Accreditation Below Entity Drop List
(1)
Name

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting "Is the
organization
affiliated with a
health care
entity?" displays
Type of Affiliation,
Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP
entries. United
States is selected
by default.

Address

Accreditation Below Entity Text Entry
(1)
Country

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting "Is the
organization
affiliated with a
health care
entity?" 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

Other

Address Line 2

Accreditation Below
(1)
Address

Text Entry

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting "Is the
organization
affiliated with a
health care
entity?" displays
Type of Affiliation,
Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP entries.

City

Accreditation Below
Text Entry
(1)
Address Line
2

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting "Is the
organization
affiliated with a
health care
entity?" displays
Type of Affiliation,
Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP entries.

State

Accreditation Beside City
(1)

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting "Is the
organization
affiliated with a
health care
entity?" displays
Type of Affiliation,
Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP entries.

Drop List

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

ZIP

Accreditation Below State
(1)

Text Entry

The field is
displayed if the
user selects the
checkbox for "Is
the organization
affiliated with a
health care
entity?"

Selecting "Is the
organization
affiliated with a
health care
entity?" displays
Type of Affiliation,
Entity
Name, Country,
Address, Address
Line 2, City, State
and ZIP entries.

Description

Accreditation Below Select Text Entry
(2)
up to 5
actions

The field is
displayed if the
user selects an
adverse action
that requires a
description.

Description

Accreditation Below Basis Text Entry
(2)
for Action(s)

The field is
displayed if the
user selects a
basis for action
that requires a
description.

State Changes
Label

PDF Name

Item
Type

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

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

License Number

Accreditation Text Entry Text entry is disabled if the user selects
the "No/ Not sure" option for "Does
the organization have a license?"

Select a Basis for
Action

Accreditation 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.