Form 4 DEA_Federal Licensure

DEA_Federal Licensure Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response Visibility Trigger
Input
Item

Other

Date of Death

DEA_Federal
Licensure (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

DEA_Federal
Licensure (1)

Below Organization
Type

Text
Entry

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

Specialty

DEA_Federal
Licensure (1)

Beside Profession or Text
Field of Licensure
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

DEA_Federal
Licensure (1)

Beside Profession or Drop List The field is
Field of Licensure
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.

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input
Item

Other

FEIN (Federal
Employer
Identification
Number)

DEA_Federal
Licensure (1)

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

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.

UPIN (Unique
Physician
Identification
Numbers)

DEA_Federal
Licensure (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.

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.

FDA (Federal Food DEA_Federal
and Drug
Licensure (1)
Administration)

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input
Item

CLIA (Clinical
DEA_Federal
Laboratory
Licensure (1)
Improvement Act)

Below text entry
FDA (Federal Food
and Drug
Administration)

Text
Entry

Type of Affiliation DEA_Federal
Licensure (1)

Below "Is the
practitioner
affiliated with a
health care entity?"
checkbox

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.

Entity Name

Below Type of
Affiliation

Text
Entry

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

DEA_Federal
Licensure (1)

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?"

Other

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

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

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input
Item

Other

Country

DEA_Federal
Licensure (1)

Below "Is the
practitioner
affiliated with a
health care entity?"
checkbox

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. United
States is the
default selection.

Address

DEA_Federal
Licensure (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

DEA_Federal
Licensure (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

DEA_Federal
Licensure (1)

Below Address Line
2

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 Visibility Trigger
Input
Item

Other

State

DEA_Federal
Licensure (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

DEA_Federal
Licensure (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

DEA_Federal
Licensure (2)

Below an action
requiring a
description

Text
Entry

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

Description

DEA_Federal
Licensure (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

DEA_Federal
Licensure (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.

Label

PDF Name
(step)

Location

Response Visibility Trigger
Input
Item

Other

Period of time
type

DEA_Federal
Licensure (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.

Is reinstatement
automatic after
this period of
time?

DEA_Federal
Licensure (2)

Below “How long
will it remain in
effect?”

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)

Date of Appeal

DEA_Federal
Licensure (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

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

DEA_Federal
Licensure

Modal

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

Select an
Profession or
Field of
Licensure

DEA_Federal
Licensure

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.

Other Name for DEA_Federal
Occupation
Licensure

Text Entry

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

License
Number

DEA_Federal
Licensure

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

DEA_Federal
Licensure

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.