<required value="true" /> <group> <extension url="http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup"> <valueCode value="header" /> </extension> <linkId value="HERF/header" /> <question> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="3" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="9" /> </extension> <linkId value="HERF/DE2" /> <text value="Event ID" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE30" /> <text value="Initial Report Date" /> <type value="string" /> <required value="true" /> </question> </group> <group> <linkId value="HERF/SEC01" /> <question> <linkId value="HERF/DE30b" /> <text value="Report Date" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE3" /> <text value="What is being reported?" /> <type value="open-choice" /> <required value="true" /> <options> <reference value="#d1e5879-vs" /> </options> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs"> <valueInteger value="0" /> </extension> <linkId value="HERF/DE15" /> <text value="Briefly describe the event that occurred or unsafe condition" /> <type value="string" /> <required value="true" /> <repeats value="true" /> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs"> <valueInteger value="0" /> </extension> <linkId value="HERF/DE18" /> <text value="Briefly describe the location where the event occurred or where the unsafe condition exists" /> <type value="string" /> <required value="true" /> <repeats value="true" /> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs"> <valueInteger value="10" /> </extension> <linkId value="HERF/DE21" /> <text value="Which of the following categories are associated with the event or unsafe condition?" /> <type value="open-choice" /> <required value="true" /> <repeats value="true" /> <options> <reference value="#d1e6177-vs" /> </options> </question> </group> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="#enableWhen.question"> <valueString value="HERF/DE3" /> </extension> <extension url="#enableWhen.answer"> <valueCoding> <system value="http://ahrq.org/form/question_identifier#HERF/DE3-cs" /> <code value="A3" /> </valueCoding> </extension> </extension> <linkId value="HERF/SEC01.1" /> <title value="PATIENT INFORMATION (COMPLETE ONLY IF INCIDENT)" /> <text value="Please complete the patient identifiers below. Additional patient information is captured on the Patient Information Form (PIF). (When reporting a perinatal incident that affected a mother and a neonate, please complete the patient identifiers below for the mother (Q8 – Q11) and the neonate (Q12 – Q15). Please also complete a separate PIF for the neonate involved.)" /> <question> <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat"> <valueString value="MM/DD/YYYY" /> </extension> <linkId value="HERF/DE9a" /> <text value="Event Discovery Date" /> <type value="string" /> <required value="true" /> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-defaultValue"> <valueCoding> <system value="HERF/DE9b-cs" /> <code value="UNK" /> <display value="Unknown" /> </valueCoding> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat"> <valueString value="HHMM" /> </extension> <linkId value="HERF/DE9b" /> <text value="Event Discovery Time" /> <type value="string" /> <required value="true" /> </question> </group> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="#enableWhen.question"> <valueString value="HERF/DE3" /> </extension> <extension url="#enableWhen.answer"> <valueCoding> <system value="http://ahrq.org/form/question_identifier#HERF/DE3-cs" /> <code value="A3" /> </valueCoding> </extension> </extension> <linkId value="HERF/SEC02" /> <title value="Patient Information (COMPLETE ONLY IF INCIDENT):" /> <text value="Please complete the patient identifiers below. Additional patient information is captured on the Patient Information Form (PIF). (When reporting a perinatal incident that affected a mother and a neonate, please complete the patient identifiers below for the mother (Q8 – Q11) and the neonate (Q12 – Q15). Please also complete a separate PIF for the neonate involved.)" /> <question> <linkId value="HERF/DE46" /> <text value="Patient's Name" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE47" /> <text value="Patient's Date of Birth" /> <type value="string" /> </question> <question> <linkId value="HERF/DE49" /> <text value="Patient's Medical Record #" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE42" /> <text value="Patients' Gender" /> <type value="open-choice" /> <options> <reference value="#d1e6853-vs" /> </options> </question> </group> <group> <linkId value="HERF/SEC03" /> <title value="Neonatal Patient Information:" /> <text value="COMPLETE ONLY FOR NEONATE AFFECTED BY PERINATAL INCIDENT" /> <question> <linkId value="HERF/Hidden" /> <text value="Is this event a perinatal incident that affected a neonate?" /> <type value="open-choice" /> <options> <reference value="#d1e7006-vs" /> </options> <group> <linkId value="HERF/DE34/A15" /> <required value="false" /> <repeats value="false" /> <question> <linkId value="HERF/DE34" /> <text value="Neonate's Name" /> <type value="string" /> </question> <question> <linkId value="HERF/DE37" /> <text value="Neonate's Date of Birth" /> <type value="string" /> </question> <question> <linkId value="HERF/DE40" /> <text value="Neonate's Medical Record #" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE43" /> <text value="Neonate's Gender" /> <type value="open-choice" /> <required value="true" /> <options> <reference value="#d1e7220-vs" /> </options> </question> </group> </question> </group> <group> <linkId value="HERF/SEC04" /> <title value="REPORT AND EVENT REPORTER INFORMATION" /> <question> <linkId value="HERF/DE33" /> <text value="Anonymous Reporter" /> <type value="open-choice" /> <options> <reference value="#d1e7422-vs" /> </options> <group> <linkId value="HERF/DE33/A18" /> <required value="false" /> <repeats value="false" /> <question> <linkId value="HERF/DE50" /> <text value="Reporter's Name" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE52" /> <text value="Telephone Number" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE53" /> <text value="Email Address" /> <type value="string" /> <required value="true" /> </question> <question> <linkId value="HERF/DE36" /> <text value="Reporter's Job or Position" /> <type value="string" /> </question> </group> </question> </group> <group> <linkId value="HERF/SEC05" /> <title value="Thank you for completing these questions." /> <text value="OMB No. 0935-0143 Exp. Date 10/31/2014 Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850." /> </group> <group> <extension url="http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup"> <valueCode value="footer" /> </extension> <linkId value="HERF/footer" /> <text value="AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance" /> </group> </group> </Questionnaire>

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    <required value="true" />
    <group>
      <extension url="http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup">
        <valueCode value="header" />
      </extension>
      <linkId value="HERF/header" />
      <question>
        <extension url="http://hl7.org/fhir/StructureDefinition/minLength">
          <valueInteger value="3" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength">
          <valueInteger value="9" />
        </extension>
        <linkId value="HERF/DE2" />
        <text value="Event ID" />
        <type value="string" />
        <required value="true" />
      </question>
      <question>
        <linkId value="HERF/DE30" />
        <text value="Initial Report Date" />
        <type value="string" />
        <required value="true" />
      </question>
    </group>
    <group>
      <linkId value="HERF/SEC01" />
      <question>
        <linkId value="HERF/DE30b" />
        <text value="Report Date" />
        <type value="string" />
        <required value="true" />
      </question>
      <question>
        <linkId value="HERF/DE3" />
        <text value="What is being reported?" />
        <type value="open-choice" />
        <required value="true" />
        <options>
          <reference value="#d1e5879-vs" />
        </options>
      </question>
      <question>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs">
          <valueInteger value="0" />
        </extension>
        <linkId value="HERF/DE15" />
        <text value="Briefly describe the event that occurred or unsafe condition" />
        <type value="string" />
        <required value="true" />
        <repeats value="true" />
      </question>
      <question>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs">
          <valueInteger value="0" />
        </extension>
        <linkId value="HERF/DE18" />
        <text value="Briefly describe the location where the event occurred or where the unsafe condition exists" />
        <type value="string" />
        <required value="true" />
        <repeats value="true" />
      </question>
      <question>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs">
          <valueInteger value="10" />
        </extension>
        <linkId value="HERF/DE21" />
        <text value="Which of the following categories are associated with the event or unsafe condition?" />
        <type value="open-choice" />
        <required value="true" />
        <repeats value="true" />
        <options>
          <reference value="#d1e6177-vs" />
        </options>
      </question>
    </group>
    <group>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen">
        <extension url="#enableWhen.question">
          <valueString value="HERF/DE3" />
        </extension>
        <extension url="#enableWhen.answer">
          <valueCoding>
            <system value="http://ahrq.org/form/question_identifier#HERF/DE3-cs" />
            <code value="A3" />
          </valueCoding>
        </extension>
      </extension>
      <linkId value="HERF/SEC01.1" />
      <title value="PATIENT INFORMATION (COMPLETE ONLY IF INCIDENT)" />
      <text value="Please complete the patient identifiers below. Additional patient information is captured on the Patient Information Form (PIF). (When reporting a perinatal incident that affected a mother and a neonate, please complete the patient identifiers below for the mother (Q8 – Q11) and the neonate (Q12 – Q15). Please also complete a separate PIF for the neonate involved.)" />
      <question>
        <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat">
          <valueString value="MM/DD/YYYY" />
        </extension>
        <linkId value="HERF/DE9a" />
        <text value="Event Discovery Date" />
        <type value="string" />
        <required value="true" />
      </question>
      <question>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-defaultValue">
          <valueCoding>
            <system value="HERF/DE9b-cs" />
            <code value="UNK" />
            <display value="Unknown" />
          </valueCoding>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat">
          <valueString value="HHMM" />
        </extension>
        <linkId value="HERF/DE9b" />
        <text value="Event Discovery Time" />
        <type value="string" />
        <required value="true" />
      </question>
    </group>
    <group>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen">
        <extension url="#enableWhen.question">
          <valueString value="HERF/DE3" />
        </extension>
        <extension url="#enableWhen.answer">
          <valueCoding>
            <system value="http://ahrq.org/form/question_identifier#HERF/DE3-cs" />
            <code value="A3" />
          </valueCoding>
        </extension>
      </extension>
      <linkId value="HERF/SEC02" />
      <title value="Patient Information (COMPLETE ONLY IF INCIDENT):" />
      <text value="Please complete the patient identifiers below. Additional patient information is captured on the Patient Information Form (PIF). (When reporting a perinatal incident that affected a mother and a neonate, please complete the patient identifiers below for the mother (Q8 – Q11) and the neonate (Q12 – Q15). Please also complete a separate PIF for the neonate involved.)" />
      <question>
        <linkId value="HERF/DE46" />
        <text value="Patient's Name" />
        <type value="string" />
        <required value="true" />
      </question>
      <question>
        <linkId value="HERF/DE47" />
        <text value="Patient's Date of Birth" />
        <type value="string" />
      </question>
      <question>
        <linkId value="HERF/DE49" />
        <text value="Patient's Medical Record #" />
        <type value="string" />
        <required value="true" />
      </question>
      <question>
        <linkId value="HERF/DE42" />
        <text value="Patients' Gender" />
        <type value="open-choice" />
        <options>
          <reference value="#d1e6853-vs" />
        </options>
      </question>
    </group>
    <group>
      <linkId value="HERF/SEC03" />
      <title value="Neonatal Patient Information:" />
      <text value="COMPLETE ONLY FOR NEONATE AFFECTED BY PERINATAL INCIDENT" />
      <question>
        <linkId value="HERF/Hidden" />
        <text value="Is this event a perinatal incident that affected a neonate?" />
        <type value="open-choice" />
        <options>
          <reference value="#d1e7006-vs" />
        </options>
        <group>
          <linkId value="HERF/DE34/A15" />
          <required value="false" />
          <repeats value="false" />
          <question>
            <linkId value="HERF/DE34" />
            <text value="Neonate's Name" />
            <type value="string" />
          </question>
          <question>
            <linkId value="HERF/DE37" />
            <text value="Neonate's Date of Birth" />
            <type value="string" />
          </question>
          <question>
            <linkId value="HERF/DE40" />
            <text value="Neonate's Medical Record #" />
            <type value="string" />
            <required value="true" />
          </question>
          <question>
            <linkId value="HERF/DE43" />
            <text value="Neonate's Gender" />
            <type value="open-choice" />
            <required value="true" />
            <options>
              <reference value="#d1e7220-vs" />
            </options>
          </question>
        </group>
      </question>
    </group>
    <group>
      <linkId value="HERF/SEC04" />
      <title value="REPORT AND EVENT REPORTER INFORMATION" />
      <question>
        <linkId value="HERF/DE33" />
        <text value="Anonymous Reporter" />
        <type value="open-choice" />
        <options>
          <reference value="#d1e7422-vs" />
        </options>
        <group>
          <linkId value="HERF/DE33/A18" />
          <required value="false" />
          <repeats value="false" />
          <question>
            <linkId value="HERF/DE50" />
            <text value="Reporter's Name" />
            <type value="string" />
            <required value="true" />
          </question>
          <question>
            <linkId value="HERF/DE52" />
            <text value="Telephone Number" />
            <type value="string" />
            <required value="true" />
          </question>
          <question>
            <linkId value="HERF/DE53" />
            <text value="Email Address" />
            <type value="string" />
            <required value="true" />
          </question>
          <question>
            <linkId value="HERF/DE36" />
            <text value="Reporter's Job or Position" />
            <type value="string" />
          </question>
        </group>
      </question>
    </group>
    <group>
      <linkId value="HERF/SEC05" />
      <title value="Thank you for completing these questions." />
      <text value="OMB No. 0935-0143 Exp. Date 10/31/2014 Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850." />
    </group>
    <group>
      <extension url="http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup">
        <valueCode value="footer" />
      </extension>
      <linkId value="HERF/footer" />
      <text value="AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance" />
    </group>
  </group>
</Questionnaire>