Package | hl7.fhir.us.sirb |
Type | Questionnaire |
Id | Id |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/sirb/https://build.fhir.org/ig/HL7/fhir-sirb/Questionnaire-sirb-initiate-study-questionnaire-populate.html |
Url | http://hl7.org/fhir/us/sirb/Questionnaire/sirb-initiate-study-questionnaire-populate |
Version | 1.0.0 |
Status | draft |
Date | 2023-04-24T20:03:27+00:00 |
Name | SIRBInitiateAStudyQuestionnaire |
Title | Initiate a Study Questionnaire |
Experimental | False |
Realm | us |
Authority | hl7 |
Description | Initiate a Study Questionnaire |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
LinkId | Text | Cardinality | Type | Flags | Description & Constraints |
---|---|---|---|---|---|
SIRBInitiateAStudyQuestionnaire | Initiate a Study Questionnaire | Questionnaire | http://hl7.org/fhir/us/sirb/Questionnaire/sirb-initiate-study-questionnaire-populate#1.0.0 | ||
in1 | Research Study Details | 0..1 | group | ||
in1.1 | Study Title | 1..1 | string | ||
in1.1_help | The official title of a protocol used to identify a clinical study.Include phase (e.g. pilot proof of concept study, phase I, phase II, etc.), design (e.g. randomized, double blind, placebo controlled, etc.), if the study is multi-center, the investigational agent (drug, device, biologic, vaccine, procedural and/or behavioral etc., and target disease(s) | 0..1 | display | ||
in1.2 | Study Title (Short) | 1..1 | string | ||
in1.2_help | A short study title written in language intended for the lay public. | 0..1 | display | ||
in1.3 | IRB Protocol Number | 1..1 | string | ||
in1.3_help | The Protocol Number assigned by the sIRB | 0..1 | display | ||
in1.4 | Study Type | 1..1 | choice | Options: 2 options | |
in1.4_help | Select the study type, either Interventional (Clinical Trial) or Observational (Non-Interventional) | 0..1 | display | ||
DIVIDER1 | null | 0..1 | display | ||
in5 | Other Organization(s) Involved | 0..* | group | ||
in5.1 | Relationship Type | 1..1 | choice | Options: 2 options | |
in5.1_help | Select the organization's type of involvement in the study | 0..1 | display | ||
in5.2 | Organization Name | 1..1 | string | ||
in5.2_help | e.g. NIH or company name | 0..1 | display | ||
in5.3 | Phone | 0..1 | string | ||
in5.3_help | 10 digit phone number, including area code | 0..1 | display | ||
in5.4 | Sponsor or Funding Source Protocol Number, if applicable | 0..1 | string | ||
in5.4_help | Unique Protocol Identification Number used by the sponsor, if applicable | 0..1 | display | ||
in5.5 | Other Organization Name, Relationship Type, Phone and Protocol Number (read-only) | 0..1 | string | Expressions:
| |
in5.6 | Protocol Number with Organization Name (read-only) | 0..1 | string | Expressions:
| |
DIVIDER2 | null | 0..1 | display | ||
in6 | sIRB (Reviewing Institution) | 0..1 | group | ||
in6.1 | sIRB (Reviewing Institution) Name | 1..1 | string | ||
in6.1_help | Name of the sIRB (Reviewing Institution) | 0..1 | display | ||
in6.10 | Department Name or Division | 0..1 | string | ||
in6.10_help | The department name or division of the sIRB, if applicable | 0..1 | display | ||
in6.3 | Institution Street Address | 1..1 | string | ||
in6.3_help | Physical address of the sIRB (Reviewing Institution) | 0..1 | display | ||
in6.4 | Institution City | 1..1 | string | ||
in6.5 | Institution State | 1..1 | string | ||
in6.6 | Institution Zip Code | 1..1 | string | ||
in6.7 | Institution Country | 0..1 | string | Initial Value: string = United States | |
in6.8 | Is a Federal Wide Assurance (FWA) Number assigned? | 1..1 | choice | Options: 4 options | |
in6.8_help | DHHS assigned number indicating Assurance of Compliance with the Office of Human Research Protections. The only type of assurance of compliance accepted and approved by OHRP for institutions engaged in non-exempt human subjects research conducted or supported by HHS. Under a FWA, an institution commits to HHS that it will comply with the requirements set forth in 45 CFR 46, as well as the terms of assurance. If the user believes that there is a FWA number assigned but needs to confirm this, select "temporarily unavailable". If the user does not know if there is a FWA number assigned, select "No Information". | 0..1 | display | ||
in6.9 | Federal Wide Assurance Number (if assigned) | 0..1 | integer | Enable When: in6.8 = Yes (expandedYes-NoIndicator#Y) | |
in6.9_help | If assigned, enter just numeric value of FWA. | 0..1 | display | ||
in6.11 | Is the sIRB a 3rd party institution? | 0..1 | choice | Options: 2 options | |
in6.11_help | Is the sIRB an external 3rd party institution, outside of the lead Principal Investigator institution? | 0..1 | display | ||
DIVIDER3 | null | 0..1 | display | ||
in7 | Lead Principal Investigator | 0..1 | group | ||
in7.1 | Lead Principal Investigator Institution | 0..1 | group | ||
in7.1.1 | Lead Principal Investigator Institution Name | 1..1 | string | ||
in7.1.1_help | Name of institution for the lead principal investigator | 0..1 | display | ||
in7.1.10 | Department Name or Division | 0..1 | string | ||
in7.1.10_help | The department name or division of the lead principal investigator | 0..1 | display | ||
in7.1.3 | Institution Phone | 0..1 | string | ||
in7.1.3_help | 10-digit phone number, including area code, for the institution of the lead principal investigator | 0..1 | display | ||
in7.1.4 | Is a Federal Wide Assurance (FWA) Number assigned? | 1..1 | choice | Options: 4 options | |
in7.1.4_help | DHHS assigned number indicating Assurance of Compliance with the Office of Human Research Protections. The only type of assurance of compliance accepted and approved by OHRP for institutions engaged in non-exempt human subjects research conducted or supported by HHS. Under a FWA, an institution commits to HHS that it will comply with the requirements set forth in 45 CFR 46, as well as the terms of assurance. If the user believes that there is a FWA number assigned but needs to confirm this, select "temporarily unavailable". If the user does not know if there is a FWA number assigned, select "No Information". | 0..1 | display | ||
in7.1.5 | Federal Wide Assurance Number (if assigned) | 0..1 | integer | Enable When: in7.1.4 = Yes (expandedYes-NoIndicator#Y) | |
in7.1.5_help | If assigned, enter just numeric value of FWA. | 0..1 | display | ||
in7.3 | Lead Principal Investigator | 0..1 | group | ||
in7.3.1 | Lead Principal Investigator First Name | 1..1 | string | ||
in7.3.1_help | First Name or Given Name of the lead PI responsible for the overall study | 0..1 | display | ||
in7.3.2 | Lead Principal Investigator Last Name | 1..1 | string | ||
in7.3.2_help | Last name, surname or family name of the lead PI responsible for the overall study | 0..1 | display | ||
in7.3.3 | Lead Principal Investigator Suffix | 0..1 | string | ||
in7.3.3_help | Suffix such as Junior (Jr.), Senior (Sr.), I, II, III, IV, etc. | 0..1 | display | ||
in7.3.4 | Academic and Professional Degrees associated with the Lead Principal Investigator | 1..1 | string | ||
in7.3.4_help | Academic and Professional degrees associated with the lead principal investigator | 0..1 | display | ||
in7.3.10 | Department Name or Division | 0..1 | string | ||
in7.3.10_help | The department name or division of the lead PI | 0..1 | display | ||
in7.3.5 | Phone | 0..1 | string | ||
in7.3.5_help | 10-digit phone number, including area code, for the lead principal investigator | 0..1 | display | ||
in7.3.6 | Email address | 0..1 | string | ||
in7.3.6_help | Email address associated with the lead principal investigator | 0..1 | display | ||
in7.3.7 | Address of Lead Principal Investigator | 0..1 | group | ||
in7.3.7.1 | Street Address | 0..1 | string | ||
in7.3.7.1_help | Physical address | 0..1 | display | ||
in7.3.7.2 | City | 1..1 | string | ||
in7.3.7.3 | State | 1..1 | string | ||
in7.3.7.4 | Zip Code | 0..1 | string | ||
in7.3.7.5 | Country | 0..1 | string | Initial Value: string = United States | |
in7.9 | Lead Principal Investigator Unique Site (read-only) | 0..1 | string | Expressions:
| |
in7.10 | Lead Principal Investigator Full Name, Suffix and Degrees | 0..1 | string | Expressions:
| |
DIVIDER4 | null | 0..1 | display | ||
in8 | Relying Site(s) | 0..* | group | ||
in8.5 | Affiliation with Lead Principal Investigator Institution, Lead Principal Investigator Site or Lead Principal Investigator | 0..1 | group | ||
in8.5.1 | Is this relying site at the same institution as where the lead principal investigator is conducting the study? | 0..1 | choice | Options: 2 options | |
in8.5.1_help | This question is optional. It can be used to pre-populate the lead principal investigator institution details if this relying site is at the same institution as where the lead principal investigator is conducting the study. If you do not want pre-population to occur, you may leave this question blank. | 0..1 | display | ||
in8.5.2 | Is this relying site at the same site as where the lead principal investigator is conducting the study? | 0..1 | choice | Enable When: in8.5.1 = Yes (expandedYes-NoIndicator#Y) Options: 2 options | |
in8.5.2_help | This question is optional. It can be used to pre-populate the lead principal investigator site details if this relying site is at the same site as where the lead principal investigator is conducting the study. If you do not want pre-population to occur, you may leave this question blank. | 0..1 | display | ||
in8.5.3 | Is the relying site PI for this site the same PI as the lead principal investigator conducting the study? | 0..1 | choice | Options: 2 options | |
in8.5.3_help | This question is optional. It can be used to pre-populate the lead principal investigator details if this relying site PI is the same PI as the lead principal investigator conducting the study. If you do not want pre-population to occur, you may leave this question blank. | 0..1 | display | ||
in8.5.4 | Is this relying site also considered to be the lead site for the study? | 1..1 | choice | Options: 2 options | |
in8.5.4_help | Indicator that the lead PI site where the study is being conducted is also participating as this relying site | 0..1 | display | ||
in8.1 | Relying Site Institution | 0..1 | group | ||
in8.1.1 | Relying Institution Name | 1..1 | string | Expressions:
| |
in8.1.1_help | Name of Institution for which their IRB agrees to rely on the decisions of the reviewing IRB at their own institutions. | 0..1 | display | ||
in8.1.10 | Department Name or Division | 0..1 | string | Expressions:
| |
in8.1.10_help | The department name or division for the relying site | 0..1 | display | ||
in8.1.3 | Relying Institution Phone | 0..1 | string | Expressions:
| |
in8.1.3_help | 10-digit phone number, including area code, for the relying institution | 0..1 | display | ||
in8.1.4 | Is a Federal Wide Assurance (FWA) Number assigned? | 1..1 | choice | Options: 4 options Expressions:
| |
in8.1.4_help | DHHS assigned number indicating Assurance of Compliance with the Office of Human Research Protections. The only type of assurance of compliance accepted and approved by OHRP for institutions engaged in non-exempt human subjects research conducted or supported by HHS. Under a FWA, an institution commits to HHS that it will comply with the requirements set forth in 45 CFR 46, as well as the terms of assurance. If the user believes that there is a FWA number assigned but needs to confirm this, select "temporarily unavailable". If the user does not know if there is a FWA number assigned, select "No Information". | 0..1 | display | ||
in8.1.5 | Federal Wide Assurance Number (if assigned) | 0..1 | integer | Enable When: in8.1.4 = Yes (expandedYes-NoIndicator#Y) Expressions:
| |
in8.1.5_help | If assigned, enter just numeric value of FWA. | 0..1 | display | ||
in8.1.6 | Reliance Status | 1..1 | choice | Options: 5 options | |
in8.1.6_help | Status of the reliance agreement | 0..1 | display | ||
in8.1_help | Institution whose IRB agrees to rely on oversite by the sIRB (Reviewing IRB) | 0..1 | display | ||
in8.3 | Relying Site Principal Investigator | 0..1 | group | ||
in8.3.1 | Relying Site Principal Investigator First Name | 1..1 | string | Expressions:
| |