Package | hl7.fhir.us.sirb |
Type | Questionnaire |
Id | sirb-nonmedicalevent-questionnaire-populate |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/sirb/https://build.fhir.org/ig/HL7/fhir-sirb/Questionnaire-sirb-nonmedicalevent-questionnaire-populate.html |
URL | http://hl7.org/fhir/us/sirb/Questionnaire/sirb-nonmedicalevent-questionnaire-populate |
Version | 1.0.0 |
Status | draft |
Date | 2023-04-24T20:03:27+00:00 |
Name | NonMedical_events |
Title | Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO)/Adverse Non-Medical Event Questionnaire |
Realm | us |
Authority | hl7 |
No resources found
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Note: links and images are rebased to the (stated) source
LinkId | Text | Cardinality | Type | Flags | Description & Constraints |
---|---|---|---|---|---|
![]() ![]() | Questionnaire | http://hl7.org/fhir/us/sirb/Questionnaire/sirb-nonmedicalevent-questionnaire-populate#1.0.0 | |||
![]() ![]() ![]() | Research Study | 0..1 | group | ||
![]() ![]() ![]() ![]() | Study Title | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | Study Title from the Informed Consent | 0..1 | display | ||
![]() ![]() ![]() ![]() | IRB Protocol Number | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | Number assigned by IRB; this number is the same as that on the Consent Form | 0..1 | display | ||
![]() ![]() ![]() ![]() | Status | 0..1 | choice | Options: 4 options | |
![]() ![]() ![]() ![]() ![]() | Status of study research activities | 0..1 | display | ||
![]() ![]() ![]() ![]() | If partial, please explain: | 0..1 | text | Enable When: nme1.4 = Partial voluntary hold on some research activities for all participants (explain below) (Temporary Codes#partial) | |
![]() ![]() ![]() ![]() ![]() | Explanation for voluntary hold on new participant enrollment. | 0..1 | display | ||
![]() ![]() ![]() | Organization/Site | 0..1 | group | ||
![]() ![]() ![]() ![]() | Where Adverse Non-Medical Event Occurred | 0..1 | group | ||
![]() ![]() ![]() ![]() ![]() | Did the Adverse Non-Medical Event occur at the lead principal investigator site? | 1..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() ![]() | Select "Yes" if the Adverse Non-Medical Event occurred at the lead principal investigator site, the study coordinating center or other administrative unit for the overall study. | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Did the Adverse Non-Medical Event occur at one of the relying sites? | 1..1 | choice | Enable When: nme7.1.8 = No (expandedYes-NoIndicator#N) Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | External Data For linkId nme7.1.9 | 0..* | open-choice | ![]() | Expressions:
|
![]() ![]() ![]() ![]() ![]() | If the Adverse Non-Medical Event occurred at one of the relying sites, select the relying site in order to pre-populate the relying institution and relying site principal investigator details below. | 0..1 | choice | Enable When: | |
![]() ![]() ![]() ![]() ![]() ![]() | This question and its answer will not print on the Adverse Non-Medical Event Form but are necessary for the form logic. If you do not want pre-population to occur, leave this question blank and manually fill in the relying institution and relying site principal investigator details. | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | If the Adverse Non-Medical Event occurred at another organization (unrelated to the lead principal investigator organization/site or relying sites), fill in the details below. | 0..1 | display | Enable When: | |
![]() ![]() ![]() ![]() ![]() | Name of organization/site where the Adverse Non-Medical Event occurred | 0..1 | string | Enable When: Expressions:
| |
![]() ![]() ![]() ![]() ![]() | City | 0..1 | string | Enable When: Expressions:
| |
![]() ![]() ![]() ![]() ![]() | State | 0..1 | string | Enable When: Expressions:
| |
![]() ![]() ![]() ![]() ![]() | Country | 0..1 | string | Enable When: Expressions:
| |
![]() ![]() ![]() ![]() | Responsibility for Adverse Non-Medical Event Reporting | 0..1 | group | Enable When: | |
![]() ![]() ![]() ![]() ![]() | If the Adverse Non-Medical Event occurred at a relying site or at another organization (unrelated to the lead principal investigator organization/site or relying sites), will the lead principal investigator site be recording the Adverse Non-Medical Event? | 1..1 | choice | Enable When: nme7.1.8 = No (expandedYes-NoIndicator#N) Options: 2 options | |
![]() ![]() ![]() ![]() ![]() ![]() | Select "Yes" if the Adverse Non-Medical Event is being recorded by the lead principal investigator site, the study coordinating center or other administrative unit for the overall study. | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Name of organization/site which is recording the Adverse Non-Medical Event | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | City | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | State | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | Country | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() | Location where Adverse Non-Medical Event occurred. Adverse non-medical events are: unexpected, related or possibly related to participation in the research, and place the participants or others at a greater risk of harm than was previously known or recognized. | 0..1 | display | ||
![]() ![]() ![]() | Site Principal Investigator for the site where Adverse Non-Medical Event occurred | 0..1 | group | Enable When: | |
![]() ![]() ![]() ![]() | First Name | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | First or given name of the site PI | 0..1 | display | ||
![]() ![]() ![]() ![]() | Last Name | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | Surname or family name | 0..1 | display | ||
![]() ![]() ![]() ![]() | Suffix | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | Suffix such as Junior (Jr.), Senior (Sr.), I, II, III, IV, etc. | 0..1 | display | ||
![]() ![]() ![]() ![]() | Degree(s) | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | Professional and Academic degrees of the site principal investigator | 0..1 | display | ||
![]() ![]() ![]() ![]() | Phone | 0..1 | string | Expressions:
| |
![]() ![]() ![]() ![]() ![]() | 10 digit phone number, including area code | 0..1 | display | ||
![]() ![]() ![]() ![]() | 0..1 | string | Expressions:
| ||
![]() ![]() ![]() ![]() | Principal Investigator at Relying Site conducting the study | 0..1 | display | ||
![]() ![]() ![]() | Report | 0..1 | group | ||
![]() ![]() ![]() ![]() | Non-medical adverse event report | 0..1 | display | ||
![]() ![]() ![]() ![]() | Report Date | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() | Date report is created | 0..1 | display | ||
![]() ![]() ![]() ![]() | Report Status | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if report is the Initial report or follow-up report | 0..1 | display | ||
![]() ![]() ![]() ![]() | Select at least one of the following criteria: | 0..1 | group | ||
![]() ![]() ![]() ![]() ![]() | Details about adverse non-medical event | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | New information resulted in unexpected change in risks of the research | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() | Indicator if new information resulted in unexpected change in risks of research | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | New or increased risk | 0..1 | group | Enable When: nme3.3.4 = true | |
![]() ![]() ![]() ![]() ![]() ![]() | Date: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date new or increased risk first documented | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Date discovered: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date new or increased risk discovered | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Description: | 0..1 | text | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Description of new or increased risk | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Unanticipated Problem Involving Risk to Participants or Others | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() | Indicator if problem Involved risk to participants or others | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Unanticipated Problem | 0..1 | group | Enable When: nme3.3.6 = true | |
![]() ![]() ![]() ![]() ![]() ![]() | Event date: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date event occurred | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Date event became aware to study team: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date site research team first became aware of unanticipated problem | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Event Summary: | 0..1 | text | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Summary description of unanticipated problem | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Was this event Unexpected? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Indicator if unanticipated problem was unexpected | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | If yes, please explain: | 0..1 | text | Enable When: nme3.3.7.4 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explanation for why unanticipated problem was unexpected | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Was this event Related or Possibly Related to participation in the research? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Unanticipated problem associated with participation in the research study | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | If yes, please explain: | 0..1 | text | Enable When: nme3.3.7.6 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explanation for why unanticipated problem is associated with participation in this research | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Does this event suggest that the research places participant(s) or others at a greater Risk of harm than was previously known? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Indicator if unanticipated problem increased risk of harm to participants | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | If yes, please explain: | 0..1 | text | Enable When: nme3.3.7.8 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explanation for why unanticipated problem is associated with increased risk of harm for research participants | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Protocol Deviation (accidental or unintentional) | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() | Indicator protocol deviation was accidental or unintentional | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Protocol Deviation (Non-Compliance) | 0..1 | group | Enable When: nme3.3.8 = true | |
![]() ![]() ![]() ![]() ![]() ![]() | Date: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date non-compliance first identified | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Date discovered: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date site research team first discovered non-compliance protocol deviation | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Description: | 0..1 | text | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Description of non-compliance protocol deviation | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Does the deviation involve any of the following? (Select all that apply) | 0..1 | group | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Failure to obtain informed consent when IRB deemed required | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | Informed consent not obtained when required by IRB | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Modifying the protocol without IRB approval, except to avoid hazard to participants | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | Protocol modified without IRB approval | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Conducting research prior to IRB approval, during an IRB suspension or after IRB approval ends | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | Conducting research without IRB approval | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explain any Checked items | 0..1 | text | Enable When:
| |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explanation for why protocol deviation category checked | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Was the deviation a substantive change from the protocol adversely affecting any of the following? (Select all that apply) | 0..1 | group | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | The rights, welfare, or safety of the participants | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | The integrity of the research area | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | The participants' willingness to continue participation | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explain any Checked items | 0..1 | text | Enable When:
| |
![]() ![]() ![]() ![]() ![]() | A breach of Confidentiality | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() | Indicator of breach of confidentiality | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Breach of Confidentiality | 0..1 | group | Enable When: nme3.3.10 = true | |
![]() ![]() ![]() ![]() ![]() ![]() | Date breach occurred | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date breach of confidentiality first documented | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Date discovered: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date site study team discovered breach of confidentiality | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Description: | 0..1 | text | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Breach of confidentiality description | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Incarceration of a participant in a protocol not approved to enroll prisoners | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() | Indicator of a study participant incarcerated when the protocol is not approved for prisoner enrollment | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Incarceration | 0..1 | group | Enable When: nme3.3.12 = true | |
![]() ![]() ![]() ![]() ![]() ![]() | Date: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date site first documented participant incarceration. | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Date incarceration was discovered: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Data site study team discovered patient incarceration | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Description: | 0..1 | text | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Description of patient incarceration | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Complaint of a participant indicating unexpected risks or the compliant cannot be resolved by team | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() | Indicator if participant complaint of unexpected risks was not resolved by study team. Complaint information is related to study site. | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Participant Complaint | 0..1 | group | Enable When: nme3.3.14 = true | |
![]() ![]() ![]() ![]() ![]() ![]() | Complaint Date: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date a participant complaint was first documented | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Date received: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date site personnel first received a participant complaint | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Description: | 0..1 | text | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Description of participant unexpected risk complaint | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Other Type of Adverse Non-Medical Event | 0..1 | boolean | ||
![]() ![]() ![]() ![]() ![]() ![]() | Indicator for other type of Adverse Non-Medical Event | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() | Other Type | 0..1 | group | Enable When: nme3.3.16 = true | |
![]() ![]() ![]() ![]() ![]() ![]() | Event date: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date event occurred | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Date study team became aware of event: | 0..1 | date | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Date site research team first became aware of the event | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Event Summary: | 0..1 | text | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Summary description of the event | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Was this Adverse Non-Medical Event Unexpected? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Indicator if event was unexpected | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | If yes, please explain: | 0..1 | text | Enable When: nme3.3.17.4 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explanation for why event was unexpected | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | Was this event Related or Possibly Related to participation in the research? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Adverse Non-Medical Event association with participation in the research study | 0..1 | display | ||
![]() ![]() ![]() ![]() ![]() ![]() | If yes, please explain: | 0..1 | text | Enable When: nme3.3.17.6 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | Explanation for why the event is associated with participation in this research | 0..1 | display | ||
![]() ![]() ![]() | Reporting | 0..1 | group | ||
![]() ![]() ![]() ![]() | Reporting information to Sponsor and both relying and reviewing IRBs | 0..1 | display | ||
![]() ![]() ![]() ![]() | Was the Sponsor notified? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if Sponsor was notified of non-medical adverse event | 0..1 | display | ||
![]() ![]() ![]() ![]() | Notification date: | 0..1 | date | Enable When: nme4.1 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() | Date sponsor notified of non-medical adverse event | 0..1 | display | ||
![]() ![]() ![]() ![]() | Was the IRB notified? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if study site IRB notified of non-medical adverse event | 0..1 | display | ||
![]() ![]() ![]() ![]() | Notification date: | 0..1 | date | Enable When: nme4.3 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() | Date study site IRB notified of non-medical adverse event | 0..1 | display | ||
![]() ![]() ![]() ![]() | Were any Other Parties notified? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | Other parties notified of non-medical adverse event (such as coordinating center, other study sites, FDA) | 0..1 | display | ||
![]() ![]() ![]() ![]() | List other notified parties | 0..1 | text | Enable When: nme4.5 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() | Corrective and Preventative Action Plan | 0..1 | group | ||
![]() ![]() ![]() ![]() | Was a Root Cause analysis performed? | 0..1 | choice | Options: 3 options | |
![]() ![]() ![]() ![]() ![]() | Indicataor if analysis of underlying causes or problems that led to the non-medical adverse event was performed | 0..1 | display | ||
![]() ![]() ![]() ![]() | If yes, provide determination: | 0..1 | text | Enable When: nme5.1 = Done, performed or completed (Temporary Codes#completed) | |
![]() ![]() ![]() ![]() ![]() | Description of what the root cause analysis determined the adverse event was caused by | 0..1 | display | ||
![]() ![]() ![]() ![]() | If pending, describe status and interim findings, if any: | 0..1 | text | Enable When: nme5.1 = Pending - Currently under development (Temporary Codes#pending) | |
![]() ![]() ![]() ![]() ![]() | Describe status and any interim findings of the root cause analysis | 0..1 | display | ||
![]() ![]() ![]() ![]() | Was Corrective Action implemented? | 0..1 | choice | Options: 3 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if corrective action is implemented for non-medical adverse event | 0..1 | display | ||
![]() ![]() ![]() ![]() | If Corrective Action was implemented or is pending, provide a summary: | 0..1 | text | Enable When: | |
![]() ![]() ![]() ![]() ![]() | Summary of corrective action implemented for non-medical adverse event. If still pending, provide a status of the corrective action plan | 0..1 | display | ||
![]() ![]() ![]() ![]() | Was Preventitive Action implemented? | 0..1 | choice | Options: 3 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if preventative action for non-medical adverse event is implemented | 0..1 | display | ||
![]() ![]() ![]() ![]() | If Preventitive Action was implemented or is pending, provide a summary: | 0..1 | text | Enable When: | |
![]() ![]() ![]() ![]() ![]() | Summary of preventative action implemented for non-medical adverse event. If still pending, provide status. | 0..1 | display | ||
![]() ![]() ![]() | Study Protocol and Informed Consent | 0..1 | group | ||
![]() ![]() ![]() ![]() | Description of protocol and informed consent changes | 0..1 | display | ||
![]() ![]() ![]() ![]() | Are changes required to the Study Protocol as a result of this report? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if changes are required in study protocol resulting from the non-medical adverse event report | 0..1 | display | ||
![]() ![]() ![]() ![]() | Reason(s) why changes are not required in the Study Protocol: | 1..* | choice | ![]() | Enable When: nme6.1a = No (expandedYes-NoIndicator#N) Options: 3 options |
![]() ![]() ![]() ![]() | Justify your decision to not change the Study Protocol (for reasons other than Adverse Non-Medical Event consisted of a missed lab/assessment or missed treatment/dose): | 0..1 | text | Enable When: | |
![]() ![]() ![]() ![]() ![]() | Justification for decision not to change study protocol based upon non-medical adverse event report | 0..1 | display | ||
![]() ![]() ![]() ![]() | Are changes required to the Informed Consent as a result of this report? | 0..1 | choice | Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if changes are required to the informed consent as a result of the non-medical adverse event report | 0..1 | display | ||
![]() ![]() ![]() ![]() | Reason(s) why changes are not required in the Informed Consent: | 1..* | choice | ![]() | Enable When: nme6.3a = No (expandedYes-NoIndicator#N) Options: 3 options |
![]() ![]() ![]() ![]() | Justify your decision to not change the Informed Consent (for reasons other than Adverse Non-Medical Event consisted of a missed lab/assessment or missed treatment/dose): | 0..1 | text | Enable When: | |
![]() ![]() ![]() ![]() ![]() | Justification for decision not to change informed consent based upon non-medical adverse event report | 0..1 | display | ||
![]() ![]() ![]() ![]() | Are notifications or re-consenting of participants required as a result of changes in Study Protocol or Informed Consent? | 0..1 | choice | Enable When: Options: 2 options | |
![]() ![]() ![]() ![]() ![]() | Indicator if notification or reconsenting of participants is required due to changes in Study Protocol or Informed Consent | 0..1 | display | ||
![]() ![]() ![]() ![]() | If yes, detail how the notification and/or re-consent will occur: | 0..1 | text | Enable When: nme6.5 = Yes (expandedYes-NoIndicator#Y) | |
![]() ![]() ![]() ![]() ![]() | Description of how notification or re-consent will occur | 0..1 | display | ||
![]() ![]() ![]() ![]() | If no, justify your decision to not notify (re-consent) participants: | 0..1 | text | Enable When: nme6.5 = No (expandedYes-NoIndicator#N) | |
![]() ![]() ![]() ![]() ![]() | Rationale for not notifying (re-consenting) study participants | 0..1 | display | ||
![]() ![]() ![]() | Optional Attachments | 0..* | group | ||
![]() ![]() ![]() ![]() | Describe the file that is being attached (optional) | 0..1 | string | ||
![]() ![]() ![]() ![]() | Attachment | 0..1 | attachment | ||
![]() ![]() ![]() ![]() | Attachments related to the Adverse Non-Medical Event can be included here. | 0..1 | display | ||
![]() ![]() ![]() | Administrative Use Only | 0..1 | group | ![]() | |
![]() ![]() ![]() ![]() | Link ID prefix | 0..1 | string | ![]() | Initial Value: string = nme |
![]() ![]() ![]() ![]() | Questionnaire Response ID for the parent Questionnaire Response (such as the Initiate a Study Questionnaire Response), if any | 0..1 | string | ![]() | Initial Value: string = temporarily unavailable Expressions:
|
![]() ![]() ![]() ![]() | ID of the Research Study FHIR Resource associated with the study Questionnaire Responses | 0..1 | string | ![]() | Initial Value: string = temporarily unavailable Expressions:
|
![]() ![]() ![]() ![]() | Questionnaire Response ID of the local considerations Questionnaire Response, if any | 0..1 | string | ![]() | |
Option Sets
Answer options for nme1.4
Answer options for nme7.1.8
Answer options for nme7.1.11
Answer options for nme7.2.8
Answer options for nme3.2
Answer options for nme3.3.7.4
Answer options for nme3.3.7.6
Answer options for nme3.3.7.8
Answer options for nme3.3.17.4
Answer options for nme3.3.17.6
Answer options for nme4.1
Answer options for nme4.3
Answer options for nme4.5
Answer options for nme5.1
Answer options for nme5.3
Answer options for nme5.5
Answer options for nme6.1a
Answer options for nme6.1b
Answer options for nme6.3a
Answer options for nme6.3b
Answer options for nme6.5
{ "resourceType": "Questionnaire", "id": "sirb-nonmedicalevent-questionnaire-populate", "text": { "status": "generated", "div": "<!-- snip (see above) -->" }, "extension": [ { "extension": [ { "url": "name", "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "sourceQuestionnaireResponse", "display": "The content of the Questionnaire Response transferred to this Questionnaire during form launch" } }, { "url": "type", "valueCode": "QuestionnaireResponse" }, { "url": "description", "valueString": "The Initiate a Study Questionnaire Response content that will be used to pre-populate this Questionnaire" } ], "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext" }, { "url": "http://hl7.org/fhir/StructureDefinition/variable", "valueExpression": { "description": "variable to store the incoming data from the launchContext extension for populate and other expressions", "name": "lookupInitiateStudy", "language": "text/fhirpath", "expression": "%sourceQuestionnaireResponse" } }, { "url": "http://hl7.org/fhir/StructureDefinition/variable", "valueExpression": { "description": "event happened at the lead PI site/coordinating center", "name": "eventOccurredAtLeadPISite", "language": "text/fhirpath", "expression": "%resource.descendants().where(linkId = 'nme7.1.8').answer.valueCoding.code" } }, { "url": "http://hl7.org/fhir/StructureDefinition/variable", "valueExpression": { "description": "relying site where NME occurred", "name": "relyingSiteForForm", "language": "text/fhirpath", "expression": "%resource.descendants().where(linkId = 'nme7.1.9').answer.value.display" } }, { "url": "http://hl7.org/fhir/StructureDefinition/variable", "valueExpression": { "description": "being reported by lead PI site", "name": "relyingSiteEventReportedByLeadPISite", "language": "text/fhirpath", "expression": "%resource.descendants().where(linkId = 'nme7.2.8').answer.valueCoding.code" } } ], "url": "http://hl7.org/fhir/us/sirb/Questionnaire/sirb-nonmedicalevent-questionnaire-populate", "version": "1.0.0", "name": "NonMedical_events", "title": "Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO)/Adverse Non-Medical Event Questionnaire", "status": "draft", "experimental": false, "subjectType": [ "ResearchStudy" ], "date": "2023-04-24T20:03:27+00:00", "publisher": "HL7 International - BR&R Work Group", "contact": [ { "name": "HL7 International - Biomedical Research and Regulation", "telecom": [ { "system": "url", "value": "http://www.hl7.org/Special/committees/rcrim" } ] } ], "jurisdiction": [ { "coding": [ { "system": "urn:iso:std:iso:3166", "code": "US", "display": "United States of America" } ], "text": "United States of America" } ], "item": [ { "linkId": "nme1", "text": "Research Study", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#274e90; font-size: 150%" } ] }, "type": "group", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression": { "language": "text/fhirpath", "expression": "%lookupInitiateStudy.descendants().where(linkId = 'in1.2').answer.value" } } ], "linkId": "nme1.1", "text": "Study Title", "type": "string", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme1.1_help", "text": "Study Title from the Informed Consent", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression": { "language": "text/fhirpath", "expression": "%lookupInitiateStudy.descendants().where(linkId = 'in1.3').answer.value" } } ], "linkId": "nme1.3", "text": "IRB Protocol Number", "type": "string", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme1.3_help", "text": "Number assigned by IRB; this number is the same as that on the Consent Form", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme1.4", "text": "Status", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "nochange", "display": "No change in research activities" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "stopped", "display": "All research activities temporarily and voluntarily stopped for all participants" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "partial", "display": "Partial voluntary hold on some research activities for all participants (explain below)" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "hold", "display": "Voluntary hold on new participant enrollment only" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme1.4_help", "text": "Status of study research activities", "type": "display" } ] }, { "linkId": "nme1.5", "text": "If partial, please explain:", "type": "text", "enableWhen": [ { "question": "nme1.4", "operator": "=", "answerCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "partial" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme1.5_help", "text": "Explanation for voluntary hold on new participant enrollment.", "type": "display" } ] } ] }, { "linkId": "nme7", "text": "Organization/Site", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#274e90; font-size: 150%" } ] }, "type": "group", "required": false, "item": [ { "linkId": "nme7.1", "text": "Where Adverse Non-Medical Event Occurred", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#2a623d; font-size: 125%" } ] }, "type": "group", "required": false, "repeats": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme7.1.8", "text": "Did the Adverse Non-Medical Event occur at the lead principal investigator site?", "type": "choice", "required": true, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme7.1.8_help", "text": "Select \"Yes\" if the Adverse Non-Medical Event occurred at the lead principal investigator site, the study coordinating center or other administrative unit for the overall study.", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme7.1.11", "text": "Did the Adverse Non-Medical Event occur at one of the relying sites?", "type": "choice", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } } ], "required": true, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression": { "language": "text/fhirpath", "expression": "%lookupInitiateStudy.repeat(item).where(linkId = 'in8.9').answer.value" } }, { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/designNote", "valueMarkdown": "See FHIR Specification Feedback Jira ticket FHIR-36338. Information obtained from other types of external sources (e.g. launch context, fhir-x-query, etc.) SHOULD only be used for initialExpression and calculatedExpression logic. Other behavior such as enableWhen or answerExpression should always be driven off of answers within the Questionnaire (even if they are hidden answers that are populated from an initialExpression)." } ], "linkId": "ExternalDataFor_nme7.1.9", "text": "External Data For linkId nme7.1.9", "type": "open-choice", "required": false, "repeats": true }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } }, { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-answerExpression", "valueExpression": { "language": "text/fhirpath", "expression": "%resource.repeat(item).where(linkId = 'ExternalDataFor_nme7.1.9').answer.value" } }, { "url": "http://hl7.org/fhir/StructureDefinition/designNote", "valueMarkdown": "See FHIR Specification Feedback Jira ticket FHIR-36338. Information obtained from other types of external sources (e.g. launch context, fhir-x-query, etc.) SHOULD only be used for initialExpression and calculatedExpression logic. Other behavior such as enableWhen or answerExpression should always be driven off of answers within the Questionnaire (even if they are hidden answers that are populated from an initialExpression)." } ], "linkId": "nme7.1.9", "text": "If the Adverse Non-Medical Event occurred at one of the relying sites, select the relying site in order to pre-populate the relying institution and relying site principal investigator details below.", "type": "choice", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } }, { "question": "nme7.1.11", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "enableBehavior": "all", "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme7.1.9_help", "text": "This question and its answer will not print on the Adverse Non-Medical Event Form but are necessary for the form logic. If you do not want pre-population to occur, leave this question blank and manually fill in the relying institution and relying site principal investigator details.", "type": "display" } ] }, { "linkId": "nme7.1.12", "text": "If the Adverse Non-Medical Event occurred at another organization (unrelated to the lead principal investigator organization/site or relying sites), fill in the details below.", "type": "display", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } }, { "question": "nme7.1.11", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } } ], "enableBehavior": "all" }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.1.1').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.1.1').answer.value)" } } ], "linkId": "nme7.1.1", "text": "Name of organization/site where the Adverse Non-Medical Event occurred", "type": "string", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } }, { "question": "nme7.1.11", "operator": "exists", "answerBoolean": true } ], "enableBehavior": "any", "required": false }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.7.2').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.7.2').answer.value)" } } ], "linkId": "nme7.1.2", "text": "City", "type": "string", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } }, { "question": "nme7.1.11", "operator": "exists", "answerBoolean": true } ], "enableBehavior": "any", "required": false }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.7.3').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.7.3').answer.value)" } } ], "linkId": "nme7.1.3", "text": "State", "type": "string", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } }, { "question": "nme7.1.11", "operator": "exists", "answerBoolean": true } ], "enableBehavior": "any", "required": false }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.7.5').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.7.5').answer.value)" } } ], "linkId": "nme7.1.4", "text": "Country", "type": "string", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } }, { "question": "nme7.1.11", "operator": "exists", "answerBoolean": true } ], "enableBehavior": "any", "required": false } ] }, { "linkId": "nme7.2", "text": "Responsibility for Adverse Non-Medical Event Reporting", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#2a623d; font-size: 125%" } ] }, "type": "group", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } }, { "question": "nme7.1.11", "operator": "exists", "answerBoolean": true } ], "enableBehavior": "any", "required": false, "repeats": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme7.2.8", "text": "If the Adverse Non-Medical Event occurred at a relying site or at another organization (unrelated to the lead principal investigator organization/site or relying sites), will the lead principal investigator site be recording the Adverse Non-Medical Event?", "type": "choice", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } } ], "required": true, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme7.2.8_help", "text": "Select \"Yes\" if the Adverse Non-Medical Event is being recorded by the lead principal investigator site, the study coordinating center or other administrative unit for the overall study.", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y' or %relyingSiteEventReportedByLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.1.1').answer.value, iif(%relyingSiteEventReportedByLeadPISite = 'N', %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.1.1').answer.value) )" } } ], "linkId": "nme7.2.1", "text": "Name of organization/site which is recording the Adverse Non-Medical Event", "type": "string", "required": false }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y' or %relyingSiteEventReportedByLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.7.2').answer.value, iif(%relyingSiteEventReportedByLeadPISite = 'N', %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.7.2').answer.value) )" } } ], "linkId": "nme7.2.2", "text": "City", "type": "string", "required": false }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y' or %relyingSiteEventReportedByLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.7.3').answer.value, iif(%relyingSiteEventReportedByLeadPISite = 'N', %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.7.3').answer.value) )" } } ], "linkId": "nme7.2.3", "text": "State", "type": "string", "required": false }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y' or %relyingSiteEventReportedByLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.7.5').answer.value, iif(%relyingSiteEventReportedByLeadPISite = 'N', %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.7.5').answer.value) )" } } ], "linkId": "nme7.2.4", "text": "Country", "type": "string", "required": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme7_help", "text": "Location where Adverse Non-Medical Event occurred. Adverse non-medical events are: unexpected, related or possibly related to participation in the research, and place the participants or others at a greater risk of harm than was previously known or recognized.", "type": "display" } ] }, { "linkId": "nme8", "text": "Site Principal Investigator for the site where Adverse Non-Medical Event occurred", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#274e90; font-size: 150%" } ] }, "type": "group", "enableWhen": [ { "question": "nme7.1.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } }, { "question": "nme7.1.11", "operator": "exists", "answerBoolean": true } ], "enableBehavior": "any", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.1').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.1').answer.value)" } } ], "linkId": "nme8.1", "text": "First Name", "type": "string", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme8.1_help", "text": "First or given name of the site PI", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.2').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.2').answer.value)" } } ], "linkId": "nme8.4", "text": "Last Name", "type": "string", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme8.4_help", "text": "Surname or family name", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.3').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.3').answer.value)" } } ], "linkId": "nme8.5", "text": "Suffix", "type": "string", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme8.5_help", "text": "Suffix such as Junior (Jr.), Senior (Sr.), I, II, III, IV, etc.", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.4').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.4').answer.value)" } } ], "linkId": "nme8.6", "text": "Degree(s)", "type": "string", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme8.6_help", "text": "Professional and Academic degrees of the site principal investigator", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.5').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.5').answer.value)" } } ], "linkId": "nme8.2", "text": "Phone", "type": "string", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme8.2_help", "text": "10 digit phone number, including area code", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression", "valueExpression": { "language": "text/fhirpath", "expression": "iif(%eventOccurredAtLeadPISite = 'Y', %lookupInitiateStudy.descendants().where(linkId = 'in7.3.6').answer.value, %lookupInitiateStudy.descendants().where(item.where(linkId = 'in8.9' and answer.value = %relyingSiteForForm)).item.descendants().where(linkId = 'in8.3.6').answer.value)" } } ], "linkId": "nme8.3", "text": "Email", "type": "string", "required": false }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme8_help", "text": "Principal Investigator at Relying Site conducting the study", "type": "display" } ] }, { "linkId": "nme3", "text": "Report", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#274e90; font-size: 150%" } ] }, "type": "group", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3_help", "text": "Non-medical adverse event report", "type": "display" }, { "linkId": "nme3.1", "text": "Report Date", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.1_help", "text": "Date report is created", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme3.2", "text": "Report Status", "type": "choice", "required": false, "repeats": false, "readOnly": false, "answerOption": [ { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "init", "display": "Initial" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "followup", "display": "Follow-up" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.2_help", "text": "Indicator if report is the Initial report or follow-up report", "type": "display" } ] }, { "linkId": "nme3.3", "text": "Select at least one of the following criteria:", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#2a623d; font-size: 125%" } ] }, "type": "group", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3_help", "text": "Details about adverse non-medical event", "type": "display" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } } ], "linkId": "nme3.3.4", "text": "New information resulted in unexpected change in risks of the research", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.4_help", "text": "Indicator if new information resulted in unexpected change in risks of research", "type": "display" } ] }, { "linkId": "nme3.3.5", "text": "New or increased risk", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#425caf; font-size: 115%; font-weight:bold" } ] }, "type": "group", "enableWhen": [ { "question": "nme3.3.4", "operator": "=", "answerBoolean": true } ], "required": false, "item": [ { "linkId": "nme3.3.5.1", "text": "Date:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.5.1_help", "text": "Date new or increased risk first documented", "type": "display" } ] }, { "linkId": "nme3.3.5.2", "text": "Date discovered:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.5.2_help", "text": "Date new or increased risk discovered", "type": "display" } ] }, { "linkId": "nme3.3.5.3", "text": "Description:", "type": "text", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.5.3_help", "text": "Description of new or increased risk", "type": "display" } ] } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } } ], "linkId": "nme3.3.6", "text": "Unanticipated Problem Involving Risk to Participants or Others", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.6_help", "text": "Indicator if problem Involved risk to participants or others", "type": "display" } ] }, { "linkId": "nme3.3.7", "text": "Unanticipated Problem", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#425caf; font-size: 115%; font-weight:bold" } ] }, "type": "group", "enableWhen": [ { "question": "nme3.3.6", "operator": "=", "answerBoolean": true } ], "required": false, "item": [ { "linkId": "nme3.3.7.1", "text": "Event date:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.1_help", "text": "Date event occurred", "type": "display" } ] }, { "linkId": "nme3.3.7.2", "text": "Date event became aware to study team:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.2_help", "text": "Date site research team first became aware of unanticipated problem", "type": "display" } ] }, { "linkId": "nme3.3.7.3", "text": "Event Summary:", "type": "text", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.3_help", "text": "Summary description of unanticipated problem", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme3.3.7.4", "text": "Was this event Unexpected?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.4_help", "text": "Indicator if unanticipated problem was unexpected", "type": "display" } ] }, { "linkId": "nme3.3.7.5", "text": "If yes, please explain:", "type": "text", "enableWhen": [ { "question": "nme3.3.7.4", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.5_help", "text": "Explanation for why unanticipated problem was unexpected", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme3.3.7.6", "text": "Was this event Related or Possibly Related to participation in the research?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.6_help", "text": "Unanticipated problem associated with participation in the research study", "type": "display" } ] }, { "linkId": "nme3.3.7.7", "text": "If yes, please explain:", "type": "text", "enableWhen": [ { "question": "nme3.3.7.6", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.7_help", "text": "Explanation for why unanticipated problem is associated with participation in this research", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme3.3.7.8", "text": "Does this event suggest that the research places participant(s) or others at a greater Risk of harm than was previously known?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.8_help", "text": "Indicator if unanticipated problem increased risk of harm to participants", "type": "display" } ] }, { "linkId": "nme3.3.7.9", "text": "If yes, please explain:", "type": "text", "enableWhen": [ { "question": "nme3.3.7.8", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.7.9_help", "text": "Explanation for why unanticipated problem is associated with increased risk of harm for research participants", "type": "display" } ] } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } } ], "linkId": "nme3.3.8", "text": "Protocol Deviation (accidental or unintentional)", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.8_help", "text": "Indicator protocol deviation was accidental or unintentional", "type": "display" } ] }, { "linkId": "nme3.3.9", "text": "Protocol Deviation (Non-Compliance)", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#425caf; font-size: 115%; font-weight:bold" } ] }, "type": "group", "enableWhen": [ { "question": "nme3.3.8", "operator": "=", "answerBoolean": true } ], "required": false, "item": [ { "linkId": "nme3.3.9.1", "text": "Date:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.9.1_help", "text": "Date non-compliance first identified", "type": "display" } ] }, { "linkId": "nme3.3.9.2", "text": "Date discovered:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.9.2_help", "text": "Date site research team first discovered non-compliance protocol deviation", "type": "display" } ] }, { "linkId": "nme3.3.9.3", "text": "Description:", "type": "text", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.9.3_help", "text": "Description of non-compliance protocol deviation", "type": "display" } ] }, { "linkId": "nme3.3.9.4", "text": "Does the deviation involve any of the following? (Select all that apply)", "type": "group", "required": false, "item": [ { "linkId": "nme3.3.9.4.1", "text": "Failure to obtain informed consent when IRB deemed required", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.9.4.1_help", "text": "Informed consent not obtained when required by IRB", "type": "display" } ] }, { "linkId": "nme3.3.9.4.2", "text": "Modifying the protocol without IRB approval, except to avoid hazard to participants", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.9.4.2_help", "text": "Protocol modified without IRB approval", "type": "display" } ] }, { "linkId": "nme3.3.9.4.3", "text": "Conducting research prior to IRB approval, during an IRB suspension or after IRB approval ends", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.9.4.3_help", "text": "Conducting research without IRB approval", "type": "display" } ] }, { "linkId": "nme3.3.9.4.4", "text": "Explain any Checked items", "type": "text", "enableWhen": [ { "question": "nme3.3.9.4.1", "operator": "=", "answerBoolean": true }, { "question": "nme3.3.9.4.2", "operator": "=", "answerBoolean": true }, { "question": "nme3.3.9.4.3", "operator": "=", "answerBoolean": true } ], "enableBehavior": "any", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.9.4.4_help", "text": "Explanation for why protocol deviation category checked", "type": "display" } ] } ] }, { "linkId": "nme3.3.9.5", "text": "Was the deviation a substantive change from the protocol adversely affecting any of the following? (Select all that apply)", "type": "group", "required": false, "item": [ { "linkId": "nme3.3.9.5.1", "text": "The rights, welfare, or safety of the participants", "type": "boolean", "required": false }, { "linkId": "nme3.3.9.5.2", "text": "The integrity of the research area", "type": "boolean", "required": false }, { "linkId": "nme3.3.9.5.3", "text": "The participants' willingness to continue participation", "type": "boolean", "required": false }, { "linkId": "nme3.3.9.5.4", "text": "Explain any Checked items", "type": "text", "enableWhen": [ { "question": "nme3.3.9.5.1", "operator": "=", "answerBoolean": true }, { "question": "nme3.3.9.5.2", "operator": "=", "answerBoolean": true }, { "question": "nme3.3.9.5.3", "operator": "=", "answerBoolean": true } ], "enableBehavior": "any", "required": false } ] } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } } ], "linkId": "nme3.3.10", "text": "A breach of Confidentiality", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.10_help", "text": "Indicator of breach of confidentiality", "type": "display" } ] }, { "linkId": "nme3.3.11", "text": "Breach of Confidentiality", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#425caf; font-size: 115%; font-weight:bold" } ] }, "type": "group", "enableWhen": [ { "question": "nme3.3.10", "operator": "=", "answerBoolean": true } ], "required": false, "item": [ { "linkId": "nme3.3.11.1", "text": "Date breach occurred", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.11.1_help", "text": "Date breach of confidentiality first documented", "type": "display" } ] }, { "linkId": "nme3.3.11.2", "text": "Date discovered:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.11.2_help", "text": "Date site study team discovered breach of confidentiality", "type": "display" } ] }, { "linkId": "nme3.3.11.3", "text": "Description:", "type": "text", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.11.3_help", "text": "Breach of confidentiality description", "type": "display" } ] } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } } ], "linkId": "nme3.3.12", "text": "Incarceration of a participant in a protocol not approved to enroll prisoners", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.12_help", "text": "Indicator of a study participant incarcerated when the protocol is not approved for prisoner enrollment", "type": "display" } ] }, { "linkId": "nme3.3.13", "text": "Incarceration", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#425caf; font-size: 115%; font-weight:bold" } ] }, "type": "group", "enableWhen": [ { "question": "nme3.3.12", "operator": "=", "answerBoolean": true } ], "required": false, "item": [ { "linkId": "nme3.3.13.1", "text": "Date:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.13.1_help", "text": "Date site first documented participant incarceration.", "type": "display" } ] }, { "linkId": "nme3.3.13.2", "text": "Date incarceration was discovered:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.13.2_help", "text": "Data site study team discovered patient incarceration", "type": "display" } ] }, { "linkId": "nme3.3.13.3", "text": "Description:", "type": "text", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.13.3_help", "text": "Description of patient incarceration", "type": "display" } ] } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } } ], "linkId": "nme3.3.14", "text": "Complaint of a participant indicating unexpected risks or the compliant cannot be resolved by team", "type": "boolean", "required": false, "repeats": false, "readOnly": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.14_help", "text": "Indicator if participant complaint of unexpected risks was not resolved by study team. Complaint information is related to study site.", "type": "display" } ] }, { "linkId": "nme3.3.15", "text": "Participant Complaint", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#425caf; font-size: 115%; font-weight:bold" } ] }, "type": "group", "enableWhen": [ { "question": "nme3.3.14", "operator": "=", "answerBoolean": true } ], "required": false, "item": [ { "linkId": "nme3.3.15.1", "text": "Complaint Date:", "type": "date", "required": false, "repeats": false, "readOnly": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.15.1_help", "text": "Date a participant complaint was first documented", "type": "display" } ] }, { "linkId": "nme3.3.15.2", "text": "Date received:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.15.2_help", "text": "Date site personnel first received a participant complaint", "type": "display" } ] }, { "linkId": "nme3.3.15.3", "text": "Description:", "type": "text", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.15.3_help", "text": "Description of participant unexpected risk complaint", "type": "display" } ] } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } } ], "linkId": "nme3.3.16", "text": "Other Type of Adverse Non-Medical Event", "type": "boolean", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.16_help", "text": "Indicator for other type of Adverse Non-Medical Event", "type": "display" } ] }, { "linkId": "nme3.3.17", "text": "Other Type", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#425caf; font-size: 115%; font-weight:bold" } ] }, "type": "group", "enableWhen": [ { "question": "nme3.3.16", "operator": "=", "answerBoolean": true } ], "required": false, "item": [ { "linkId": "nme3.3.17.1", "text": "Event date:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.17.1_help", "text": "Date event occurred", "type": "display" } ] }, { "linkId": "nme3.3.17.2", "text": "Date study team became aware of event:", "type": "date", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.17.2_help", "text": "Date site research team first became aware of the event", "type": "display" } ] }, { "linkId": "nme3.3.17.3", "text": "Event Summary:", "type": "text", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.17.3_help", "text": "Summary description of the event", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme3.3.17.4", "text": "Was this Adverse Non-Medical Event Unexpected?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.17.4_help", "text": "Indicator if event was unexpected", "type": "display" } ] }, { "linkId": "nme3.3.17.5", "text": "If yes, please explain:", "type": "text", "enableWhen": [ { "question": "nme3.3.17.4", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.17.5_help", "text": "Explanation for why event was unexpected", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme3.3.17.6", "text": "Was this event Related or Possibly Related to participation in the research?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.17.6_help", "text": "Adverse Non-Medical Event association with participation in the research study", "type": "display" } ] }, { "linkId": "nme3.3.17.7", "text": "If yes, please explain:", "type": "text", "enableWhen": [ { "question": "nme3.3.17.6", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme3.3.17.7_help", "text": "Explanation for why the event is associated with participation in this research", "type": "display" } ] } ] } ] } ] }, { "linkId": "nme4", "text": "Reporting", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#274e90; font-size: 150%" } ] }, "type": "group", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme4_help", "text": "Reporting information to Sponsor and both relying and reviewing IRBs", "type": "display" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme4.1", "text": "Was the Sponsor notified?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme4.1_help", "text": "Indicator if Sponsor was notified of non-medical adverse event", "type": "display" } ] }, { "linkId": "nme4.2", "text": "Notification date:", "type": "date", "enableWhen": [ { "question": "nme4.1", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme4.2_help", "text": "Date sponsor notified of non-medical adverse event", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme4.3", "text": "Was the IRB notified?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme4.3_help", "text": "Indicator if study site IRB notified of non-medical adverse event", "type": "display" } ] }, { "linkId": "nme4.4", "text": "Notification date:", "type": "date", "enableWhen": [ { "question": "nme4.3", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme4.4_help", "text": "Date study site IRB notified of non-medical adverse event", "type": 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If still pending, provide a status of the corrective action plan", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme5.5", "text": "Was Preventitive Action implemented?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "completed", "display": "Done, performed or completed" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "notundertaken", "display": "Not done or undertaken" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "pending", "display": "Pending - Currently under development" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme5.5_help", "text": "Indicator if preventative action for non-medical adverse event is implemented", "type": "display" } ] }, { "linkId": "nme5.6", "text": "If Preventitive Action was implemented or is pending, provide a summary:", "type": "text", "enableWhen": [ { "question": "nme5.5", "operator": "=", "answerCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "completed" } }, { "question": "nme5.5", "operator": "=", "answerCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "pending" } } ], "enableBehavior": "any", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme5.6_help", "text": "Summary of preventative action implemented for non-medical adverse event. If still pending, provide status.", "type": "display" } ] } ] }, { "linkId": "nme6", "text": "Study Protocol and Informed Consent", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#274e90; font-size: 150%" } ] }, "type": "group", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6_help", "text": "Description of protocol and informed consent changes", "type": "display" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme6.1a", "text": "Are changes required to the Study Protocol as a result of this report?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6.1a_help", "text": "Indicator if changes are required in study protocol resulting from the non-medical adverse event report", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } }, { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation", "valueCode": "vertical" } ], "linkId": "nme6.1b", "text": "Reason(s) why changes are not required in the Study Protocol:", "type": "choice", "enableWhen": [ { "question": "nme6.1a", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } } ], "required": true, "repeats": true, "answerOption": [ { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "mla", "display": "Adverse Non-Medical Event consisted of a missed lab or assessment by a participant (which does not jeopardize the study or increase risks to other participants)" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "mtd", "display": "Adverse Non-Medical Event consisted of a missed 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"http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6.2_help", "text": "Justification for decision not to change study protocol based upon non-medical adverse event report", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme6.3a", "text": "Are changes required to the Informed Consent as a result of this report?", "type": "choice", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6.3a_help", "text": "Indicator if changes are required to the informed consent as a result of the non-medical adverse event report", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "check-box", "display": "Check-box" } ], "text": "Check-box" } }, { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation", "valueCode": "vertical" } ], "linkId": "nme6.3b", "text": "Reason(s) why changes are not required in the Informed Consent:", "type": "choice", "enableWhen": [ { "question": "nme6.3a", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } } ], "required": true, "repeats": true, "answerOption": [ { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "mla", "display": "Adverse Non-Medical Event consisted of a missed lab or assessment by a participant (which does not jeopardize the study or increase risks to other participants)" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "mtd", "display": "Adverse Non-Medical Event consisted of a missed treatment or dose by a participant (which does not jeopardize the study or increase risks to other participants" } }, { "valueCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "otherreason", "display": "Other reason" } } ] }, { "linkId": "nme6.4", "text": "Justify your decision to not change the Informed Consent (for reasons other than Adverse Non-Medical Event consisted of a missed lab/assessment or missed treatment/dose):", "type": "text", "enableWhen": [ { "question": "nme6.3a", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } }, { "question": "nme6.3b", "operator": "=", "answerCoding": { "system": "http://hl7.org/fhir/us/sirb/CodeSystem/temporarycodes", "code": "otherreason" } } ], "enableBehavior": "all", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6.4_help", "text": "Justification for decision not to change informed consent based upon non-medical adverse event report", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "drop-down", "display": "Drop down" } ], "text": "Drop down" } } ], "linkId": "nme6.5", "text": "Are notifications or re-consenting of participants required as a result of changes in Study Protocol or Informed Consent?", "type": "choice", "enableWhen": [ { "question": "nme6.1a", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } }, { "question": "nme6.3a", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "enableBehavior": "any", "required": false, "answerOption": [ { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y", "display": "Yes" } }, { "valueCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N", "display": "No" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6.5_help", "text": "Indicator if notification or reconsenting of participants is required due to changes in Study Protocol or Informed Consent", "type": "display" } ] }, { "linkId": "nme6.6", "text": "If yes, detail how the notification and/or re-consent will occur:", "type": "text", "enableWhen": [ { "question": "nme6.5", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "Y" } } ], "enableBehavior": "all", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6.6_help", "text": "Description of how notification or re-consent will occur", "type": "display" } ] }, { "linkId": "nme6.7", "text": "If no, justify your decision to not notify (re-consent) participants:", "type": "text", "enableWhen": [ { "question": "nme6.5", "operator": "=", "answerCoding": { "system": "http://terminology.hl7.org/CodeSystem/v2-0532", "code": "N" } } ], "enableBehavior": "all", "required": false, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme6.7_help", "text": "Rationale for not notifying (re-consenting) study participants", "type": "display" } ] } ] }, { "linkId": "nme11", "text": "Optional Attachments", "_text": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/rendering-style", "valueString": "color:#274e90; font-size: 150%" } ] }, "type": "group", "required": false, "repeats": true, "item": [ { "linkId": "nme11.1", "text": "Describe the file that is being attached (optional)", "type": "string" }, { "linkId": "nme11.2", "text": "Attachment", "type": "attachment" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/questionnaire-item-control", "code": "help", "display": "Help-Button" } ], "text": "Help-Button" } } ], "linkId": "nme11_help", "text": "Attachments related to the Adverse Non-Medical Event can be included here.", "type": "display" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true } ], "linkId": "ADMIN00", "text": "Administrative Use Only", "type": "group", "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true } ], "linkId": "ADMIN01", "text": "Link ID prefix", "type": "string", "required": false, "initial": [ { "valueString": "nme" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true }, { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression": { "language": "text/fhirpath", "expression": "%lookupInitiateStudy.descendants().where(linkId = 'ADMIN02').answer.value" } } ], "linkId": "ADMIN02", "text": "Questionnaire Response ID for the parent Questionnaire Response (such as the Initiate a Study Questionnaire Response), if any", "type": "string", "required": false, "initial": [ { "valueString": "temporarily unavailable" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true }, { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression": { "language": "text/fhirpath", "expression": "%lookupInitiateStudy.descendants().where(linkId = 'ADMIN03').answer.value" } } ], "linkId": "ADMIN03", "text": "ID of the Research Study FHIR Resource associated with the study Questionnaire Responses", "type": "string", "required": false, "initial": [ { "valueString": "temporarily unavailable" } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true } ], "linkId": "ADMIN04", "text": "Questionnaire Response ID of the local considerations Questionnaire Response, if any", "type": "string", "required": false } ] } ] }