Yes No Comments. SHQ Form Compliance Checklist. Sponsor Name: Anticipated Launch Date: Url (s) used for site audit: Audit performed by: Audit Date:

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1 SHQ Form Compliance Checklist Sponsor Name: Anticipated Launch Date: Url (s) used for site audit: Audit performed by: Audit Date: Documentation Received: Design/Functional Specification Yes No Comments Technical Specification Functional Requirement Audit: 1.1 Exceptions must be displayed to the applicant prior to the general information and instruction with wording identical to the paper version. 1.2 Exceptions must be answered for every family member indicated on the application. 1.3 The version number and date of the SHQ must be clearly displayed on every page of the form. As of the creation of this document, the current version is dated November 11, 2004, with recertification effective April 1, General description and instructions to the SHQ must appear first, ordered and numbered as they appear in the paper version of the SHQ (see 1.7.1) 1.5 Currently the fifth paragraph of the SHQ general description contains the following sentence: Documents may be viewed and printed by going to the WSHIP website at The WSHIP website link must be hyperlinked to the WSHIP website. 1.6 Appeal information must be included in the online SHQ after the general information and instructions, prior to the medical questions. The appeal wording should be identical to the paper version.

2 Functional Requirement Audit: 1.7 Each individual applicant s name must appear on every page of the online SHQ form 1.8 Language in an online version of the SHQ will be identical to the printed version with the following exceptions In Part I, Instructions, Question 6 applies specifically to the paper application process, and it should be removed from the online version ONLY Text for Part II, Question A should read Have you been diagnosed, treated and/or medicated for the following conditions in the last 10 years? Yes No. If yes to any, please select all that apply from the list below and then proceed to PART III. DO NOT COMPLETE B through M. UNLESS there is error-checking in place preventing applicants from continuing on to Section B when they have checked one or more Section A conditions. 1.9 All conditions must be displayed, worded ordered and numbered as they appear in the printed version of the SHQ with at minimum the yes column displayed as well. The sponsor has the option of either displaying the additional information (operated/treated. etc.) onscreen all at once, or only displaying the additional information for those instances where the applicant has selected yes to a specific condition Conditions that require additional information will have the same response options as on the SHQ Answers to all questions must be provided by the applicant. The sponsor and or sponsor s representatives may not modify or change the applicants responses to the questionnaire in any way 1.12 Answers to the health questions can not be entered or changed automatically by the system without first prompting the applicant for permission The applicant must be able to save and exit the SHQ at any point in the process and complete later The applicant must be given the option to manually complete the SHQ and mail the questionnaire in. The current version of the SHQ must be available in a PDF version for download The applicant must be able to print the completed SHQ(s) prior to submission If the applicant is applying for several family members, the applicant must fill out the SHQ for every (non-exempt) family member. The sponsor has the option of displaying all family members at once or one at a time.

3 Functional Requirement Audit: 1.17 Once the online application and SHQ have been submitted, it cannot be modified either by the applicant or the sponsor If the applicant selects Yes on Question A, and checks one or more Conditions 1-35, the applicant must have the option of either proceeding directly to the signature page or completing sections B thru M of the SHQ The text for applicant options at the end of section A must be: You have checked yes to one or more items in Section A. You may skip Sections B thru M and go directly to the signature page, or you may complete sections B thru M. This text should only appear if the applicant has checked yes to one or more items in Section A The applicant must see all conditions; as such, the format the sponsor is using to navigate through the medical questions must be placed at the bottom of each page for sections A through M The online version of the SHQ must meet Federal esignature guidelines as outlined in PL including: - Text clearly indicating that by filling out either their name or address twice in the spaces indicated, they are submitting what constitutes a legal and binding signature. - Two text boxes clearly marked where the applicant will type their name or address. Functional Requirements Additional Notes:

4 Design Requirement Audit: 1.21 sponsors must implement font size in one of two ways: - Specifying a fixed font size at a minimum of 12 point. - Specifying font size using % or em so that the user can increase or decrease the font size at their choosing using the web browser 1.22 The font selected by the sponsor must appear legible and clear on screen. The font type (i.e. Arial, Verdana, etc.) used for the online SHQ may be chosen by the sponsor 1.23 The WSHIP logo must appear at the beginning of the online SHQ, clearly indicating that this document is provided by the WSHIP and not by the sponsor If the applicant chooses to print out the SHQ to review prior to submitting or for their personal records, the printed version of the SHQ must have WSHIP branding only Design Requirements Additional Notes:

5 Usability and Accessibility Audit: 1.25 Navigational elements must be placed consistently throughout the application and SHQ process The SHQ Form must still function normally if JavaScript is disabled. If this is not possible, then a sniffer should be used to detect those instances where an applicant has disabled Javascript and direct them to an alternate version of the SHQ, either text only pages or the SHQ in a downloadable PDF format Priority 1 accessibility compliance as detailed and recommended by the W3C modified to support the SHQ Provide a text equivalent for every non-text element. This includes images, graphical representations, graphical buttons, etc Information conveyed using color should also be available without color. I.e. a green button to indicate next or go should also have the text embedded in the button or an alt tag with descriptive text Clearly identify changes in the natural language of a documents text and any text equivalents Organize pages so that they may be read without style sheets and display logically Ensure that equivalents for dynamic content are updated when the dynamic content changes Client side and server side image maps should not be used Screens should not flicker so animation or motion should not be used. This includes animated gif files and non-standard HTML tags such as <marquee> and <blink> If tables are used, row and column headers must be identified, using at a minimum HTML4 table accessibility tags and attributes If tables are used and contain two or more logical levels or row and column headers, use appropriate markup to associate data cells and header cells such as <scope> Frames should not be used to implement the SHQ If a scripting language is used to display content or create interface elements, their function should be described with alt tags 1.28 If the form cannot be displayed appropriately without the use of style sheets or JavaScript/applets then a browser/platform detector should be used to detect those instances where an applicant has disabled JavaScript and direct them to an alternate version of the SHQ, either text only pages or the SHQ in a downloadable PDF format

6 Usability & Accessibility Requirements Additional Notes: Security & Privacy Requirements Audit: 2.1 Applicants must be able to create a password protected account that allows only the applicant to access their application and SHQ information from the sponsors website 2.2 Applicant data must be submitted to the sponsor s website using and 128 bit minimum Secure Socket Layer encryption technology. 2.3 Applicant data must submitted to a secure, password protected database accessible only by appropriate sponsor staff 2.4 Sponsor must document database backup and security policies and provided to the technical consultant Security & Privacy Requirements Additional Notes:

7 Form Elements Audit: 2.5 All thirteen Yes No answers to the Lettered Questions ( Have you been diagnosed... ) at the beginning of Sections A-M must be independent radio button pairs with unique and matching name attributes 2.6 All answer groups relating to a specific conditions must be independent radio button sets with unique and matching name attributes: - LRD (3 radio buttons, where applicable) - OTM (2 radio buttons, where applicable) (includes recovered/present, operated/un-operated and Under Treatment ) - Time (3 radio buttons) 2.7 The Conditions listed below must be independent radio button sets with unique and matching name attributes 55(a)-(c) 112(a)-(c) 167(a)-(c) 206(a)-(c) 246(a)-(d) 71(a)-(b) 124(a)-(b) 171(a)-(b) 214(a)-(c) 247(a)-(b) 77(a)-(c) 126(a)-(d) 173(a)-(d) 229(a)-(c) 248(a)-(b) 78(a)-(b) 130(a)-(c) 181(a)-(c) * 236(a)-(b) 255(a)-(b) 82(a)-(c) 134(a)-(b) 183(a)-(b) 240(a)-(c) 256(a)-(d) 85(a)-(c) 137(a)-(e) 186(a)-(b) 242(a)-(b) 260(a)-(b) 87(a)-(b) 140(a)-(b) 188(a)-(b) 243(a)-(b) 272(a)-(c) 93(a)-(b) 146(a)-(b) 193(a)-(b) 244(a)-(b) 105(a)-(b) 159(a)-(b) 201(a)-(b) 245(a)-(d) 2.8 The following MUST be text boxes: - All Other conditions in sections A-M (the last questions in each section) 2.9 When any Other condition is populated, an empty text box must be generated adjacent to it: dynamically or by allowing the applicant to click an add condition button to add additional conditions. in order to specify further conditions. In the absence of dynamic generation (e.g., JavaScript), at least three (3) Other text boxes must exist where there is one. EXCEPTION: Section M should remain as is, with 9 text boxes. Form Elements Audit Additional Notes:

8 Browser/Platform Audit: 2.10 The carriers must test the online SHQ on the following browsers and platforms: PC I.E 6.0+ PC - Netscape 7.0+ MAC Mozilla Firefox 1.0+ Browser/Platform Audit Additional Notes: JavaScript & Error Checking Audit: 2.11 The sponsor must force the user to correct errors prior to submitting the SHQ. Example: The applicant selects no to the question Have you been diagnosed, treated and/or medicated for cancer in the last 10 years?, and then proceeds to select a cancer condition from the list. The applicant must be prompted to either change their answer on the question from a no to a yes, or to uncheck the condition Inconsistencies in the applicants responses may not be changed automatically; the applicant must be prompted to address the error themselves 2.13 Error checking must be implemented within a section, but not across sections.

9 JavaScript & Error Checking Audit: 2.14 The following conditions must be errorchecked in the SHQ: [Section A]: If Question A is checked Yes, at least one radio button must be checked within Conditions #1-35 [Section B (Cancers) only]: For any Yes text box that is checked in the Condition Column, one radio button MUST be checked in LRD, (where applicable) AND one radio button MUST be checked in OTM (where applicable) AND one radio button must be checked in Time. [Sections C-L]: For any Yes text box that is checked in the Condition Column, one radio button MUST be checked in OTM (where applicable) AND one radio button must be checked in Time Condition #180 ( Medications prescribed for psychiatric conditions ) only]: If the Yes text box is checked in the Condition Column of #180, at least one Yes text box must be checked in the Condition Columns of Conditions For any Other text box that is populated in the Condition Column, Yes must be checked in the same row's Condition Column JavaScript & Error Checking Audit Additional Notes: