Form 15 Government Administrative

Government Administrative Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Government Below "Is this
Administrative person
(1)
deceased?"

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

Organization
Description

Government Below
Administrative Organization
(1)
Type

Text Entry

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

Specialty

Government Beside
Administrative Profession or
(1)
Field of
Licensure

Text entry

The field is displayed
if the user selects a
profession or field of
licensure that does
not require
information for a
specialty.

“Specialty” is
displayed in place of
“Description” if the
selected profession
or field of
licensure requires
specialty
information.

Description

Government Beside
Administrative Profession or
(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.

“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)

Government Below
Text Entry
Administrative checkbox
(1)
"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.

Label

Response
Input Item

Visibility Trigger

Other

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.

CLIA (Clinical
Laboratory
Improvement
Act)

Government Below text
Text Entry
Administrative entry FDA
(1)
(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

Government Below "Is the
Drop List
Administrative practitioner
affiliated with a
(1)
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.

UPIN (Unique
Physician
Identification
Numbers)

PDF Name
(step)

Location

Government Below FEIN
Administrative text entry
(1)

FDA (Federal
Government Below
Food and Drug Administrative checkbox
Administration) (1)
"Does the
subject have a
FDA or CLIA
identification
number?"

Label

PDF Name
(step)

Location

Response
Input Item

Entity Name

Government Below Type of
Administrative Affiliation
(1)

Country

Government Below "Is the
Drop List
Administrative practitioner
(1)
affiliated with a
health care
entity?"
checkbox

Address

Address Line 2

Visibility Trigger

Text Entry 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.

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.

Government Below Country
Administrative
(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.

Government Below Address
Administrative
(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.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

City

Government Below Address Text Entry
Administrative Line 2
(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

Government Below City
Administrative
(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

Government Below State
Administrative
(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.

Select up to 5
actions

Government Below
Check
Administrative selections for a Boxes
(2)
type of action

The appropriate
fields are displayed
for the user when
either radio button is
selected for the type
of action.

Available selections
are “This action is
related to a
certification
agreements or
contracts for
participation in a
federal or state
health care
program, including
state nurse aide
registry findings”
and “This is an
“other adjudicated
action or decision.””

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Description

Government Below an
Administrative action
(2)
requiring a
description

Text Entry

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

Description

Government Below Basis of
Administrative Action(s)
(2)

Text Entry

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

Period of time
number

Government Below “How
Administrative long will it
(2)
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

Government Below “How
Administrative long will it
(2)
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.

Radio
Buttons

The fields are
displayed if the user
selects “A specific
period of time” for
“Is reinstatement
automatic after this
period of time?

Available options
are “No,” “Yes” and
“Yes with conditions
(Requires a Revision
to Action report
when status
changes)

Text Entry

The field is displayed
if the user selects
Yes option for “Is the
action on appeal?”

Is
Government
reinstatement Administrative
automatic after (2)
this period of
time?

Below “How
long will it
remain in
effect?”

Date of Appeal Government Below Is the
Administrative action on
(2)
appeal?

State Changes
Label

PDF Name

Item Type

Trigger

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

Government
Administrative

Modal

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

Select a
Profession or
Field of
Licensure

Government
Administrative

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

Government
Administrative

Text Entry

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

License
Number

Government
Administrative

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

Government
Administrative

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.