Form 10 Deferred Conviction or Pre-Trial Diversion

Deferred Conviction or Pre-Trial Diversion Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Date of Death

Deferred
Conviction
or Pre-Trial
Diversion
(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

Deferred
Conviction
or Pre-Trial
Diversion
(1)

Below
Organization
Type

Text Entry

Specialty

Deferred
Conviction
or Pre-Trial
Diversion
(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

Deferred
Conviction
or Pre-Trial
Diversion
(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)

Deferred
Conviction
or Pre-Trial
Diversion
(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

Response
Input Item

Visibility Trigger

Other

Below FEIN
text entry

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
Deferred
Food and Drug Conviction
Administration) or Pre-Trial
Diversion
(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)

Deferred
Conviction
or Pre-Trial
Diversion
(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

Deferred
Conviction
or Pre-Trial
Diversion
(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.

UPIN (Unique
Physician
Identification
Numbers)

PDF Name
(step)
Deferred
Conviction
or Pre-Trial
Diversion
(1)

Location

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Entity Name

Deferred
Conviction
or Pre-Trial
Diversion
(1)

Below Type of
Affiliation

Country

Deferred
Conviction
or Pre-Trial
Diversion
(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

Deferred
Conviction
or Pre-Trial
Diversion
(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?”

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.

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

Address Line 2

Deferred
Conviction
or Pre-Trial
Diversion
(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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

City

Deferred
Conviction
or Pre-Trial
Diversion
(1)

Below Address Text Entry
Line 2

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?”

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

Label

PDF Name
(step)

Location

Response
Input Item

Visibility Trigger

Other

State

Deferred
Conviction
or Pre-Trial
Diversion
(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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

ZIP

Deferred
Conviction
or Pre-Trial
Diversion
(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. For
organization
reports, the check
box label is “Is the
organization
affiliated with a
health care entity?”

Description

Deferred
Conviction
or Pre-Trial
Diversion
(2)

Below “Act or
Omission”

Text Entry

Date of Appeal

Deferred
Conviction
or Pre-Trial
Diversion
(2)

Below "Is the
Action on
Appeal"

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

Deferred
Conviction
or Pre-Trial
Diversion
(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

Deferred
Conviction
or Pre-Trial
Diversion
(2)

Beside Years

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

Deferred
Conviction
or Pre-Trial
Diversion
(2)

Beside Months

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

Deferred
Conviction
or Pre-Trial
Diversion
(2)

Beside Months

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

Deferred
Conviction or PreTrial Diversion

Modal

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

Profession or
Field of
Licensure

Deferred
Conviction or PreTrial Diversion

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
Deferred
for Occupation Conviction or PreTrial Diversion

Text Entry

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

License
Number

Deferred
Conviction or PreTrial Diversion

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

Select an Act
or Omission

Deferred
Conviction or PreTrial Diversion

Modal

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.