Form 41 Health Center Attestation

Health Center Attestation Form and Instruction

Non-visible Questions
Label
Why
not?

PDF Name
(step)
Health Center
Attestation(1)

Location

Response
Input Item

Below the
Text Entry
Yes and No
radio buttons

Visibility Trigger

Other

The field is displayed
if the user selects the
No radio button

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number: 09150126 Expiration Date:
mm/dd/yyyy

Health Center
Attestation

Modal

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

Add a site

Health Center
Attestation

Modal

When the user sets Selects the link “+Add
a site” the page Add a site location is
displayed as a modal. The user can
complete the required form
elements. The modal is hidden once the
user submits the additional site form
information or selects the Cancel button.