Form 42 Hospital Attestation

Hospital Attestation Form and Instruction

Non-visible Questions
Label
Why
not?

PDF Name
(step)
Hospital
Attestation
(1)

Location
Below the Yes
and No radio
buttons

Response
Input Item
Text Entry

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

Hospital
Attestation

Modal

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

Add a Profession

Hospital
Attestation

Modal

When the user sets Selects the link “+Add
a profession” the modal to add 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 and the system
adds I or the user selects the Add button.