{
  "resourceType": "Questionnaire",
  "id": "spark3",
  "meta": {
    "versionId": "spark3",
    "lastUpdated": "2015-10-02T14:04:03.782+00:00"
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Todo</div>"
  },
  "contained": [
    {
      "resourceType": "ValueSet",
      "id": "d1e5879-vs",
      "status": "active",
      "codeSystem": {
        "system": "http://AHRQ.org/form/question_identifier#HERF/DE3-cs",
        "caseSensitive": true,
        "concept": [
          {
            "code": "A3",
            "display": "Incident",
            "definition": "A patient safety event that reached the patient, whether or not the patient was harmed."
          },
          {
            "code": "A6",
            "display": "Near Miss",
            "definition": "A patient safety event that did not reach the patient."
          },
          {
            "code": "A9",
            "display": "Unsafe Condition",
            "definition": "Any circumstance that increases the probability of a patient safety event."
          }
        ]
      }
    },
    {
      "resourceType": "ValueSet",
      "id": "d1e6177-vs",
      "status": "active",
      "codeSystem": {
        "system": "http://AHRQ.org/form/question_identifier#HERF/DE21-cs",
        "caseSensitive": true,
        "concept": [
          {
            "code": "A42",
            "display": "Blood or Blood Product"
          },
          {
            "code": "A44",
            "display": "Device or Medical/Surgical Supply, including Health Information Technology (HIT)"
          },
          {
            "code": "A48",
            "display": "Fall"
          },
          {
            "code": "A51",
            "display": "Healthcare-associated Infection"
          },
          {
            "code": "A54",
            "display": "Medication or Other Substance"
          },
          {
            "code": "A57",
            "display": "Perinatal"
          },
          {
            "code": "A60",
            "display": "Pressure Ulcer"
          },
          {
            "code": "A63",
            "display": "Surgery or Anesthesia (includes invasive procedure)"
          },
          {
            "code": "A64",
            "display": "Venous Thromboembolism"
          },
          {
            "code": "A66",
            "display": "Other: PLEASE SPECIFY"
          }
        ]
      }
    },
    {
      "resourceType": "ValueSet",
      "id": "d1e6853-vs",
      "status": "active",
      "codeSystem": {
        "system": "http://AHRQ.org/form/question_identifier#HERF/DE42-cs",
        "caseSensitive": true,
        "concept": [
          {
            "code": "M",
            "display": "Male"
          },
          {
            "code": "F",
            "display": "Female"
          },
          {
            "code": "UNK",
            "display": "Unknown"
          }
        ]
      }
    },
    {
      "resourceType": "ValueSet",
      "id": "d1e7006-vs",
      "status": "active",
      "codeSystem": {
        "system": "http://AHRQ.org/form/question_identifier#HERF/Hidden-cs",
        "caseSensitive": true,
        "concept": [
          {
            "code": "A15",
            "display": "Yes"
          },
          {
            "code": "A18",
            "display": "No"
          }
        ]
      }
    },
    {
      "resourceType": "ValueSet",
      "id": "d1e7220-vs",
      "status": "active",
      "codeSystem": {
        "system": "http://AHRQ.org/form/question_identifier#HERF/DE43-cs",
        "caseSensitive": true,
        "concept": [
          {
            "code": "M",
            "display": "Male"
          },
          {
            "code": "F",
            "display": "Female"
          },
          {
            "code": "UNK",
            "display": "Unknown"
          }
        ]
      }
    },
    {
      "resourceType": "ValueSet",
      "id": "d1e7422-vs",
      "status": "active",
      "codeSystem": {
        "system": "http://AHRQ.org/form/question_identifier#HERF/DE33-cs",
        "caseSensitive": true,
        "concept": [
          {
            "code": "A15",
            "display": "Yes"
          },
          {
            "code": "A18",
            "display": "No"
          }
        ]
      }
    }
  ],
  "identifier": [
    {
      "system": "http://ahrq.org/",
      "value": "identifier/HERF/1.2"
    }
  ],
  "status": "published",
  "group": {
    "linkId": "root",
    "title": "Healthcare Event Reporting Form (HERF) Hospital Version 1.2",
    "required": true,
    "group": [
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup",
            "valueCode": "header"
          }
        ],
        "linkId": "HERF/header",
        "question": [
          {
            "extension": [
              {
                "url": "http://hl7.org/fhir/StructureDefinition/minLength",
                "valueInteger": 3
              },
              {
                "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength",
                "valueInteger": 9
              }
            ],
            "linkId": "HERF/DE2",
            "text": "Event ID",
            "type": "string",
            "required": true
          },
          {
            "linkId": "HERF/DE30",
            "text": "Initial Report Date",
            "type": "string",
            "required": true
          }
        ]
      },
      {
        "linkId": "HERF/SEC01",
        "question": [
          {
            "linkId": "HERF/DE30b",
            "text": "Report Date",
            "type": "string",
            "required": true
          },
          {
            "linkId": "HERF/DE3",
            "text": "What is being reported?",
            "type": "open-choice",
            "required": true,
            "options": {
              "reference": "#d1e5879-vs"
            }
          },
          {
            "extension": [
              {
                "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
                "valueInteger": 0
              }
            ],
            "linkId": "HERF/DE15",
            "text": "Briefly describe the event that occurred or unsafe condition",
            "type": "string",
            "required": true,
            "repeats": true
          },
          {
            "extension": [
              {
                "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
                "valueInteger": 0
              }
            ],
            "linkId": "HERF/DE18",
            "text": "Briefly describe the location where the event occurred or where the unsafe condition exists",
            "type": "string",
            "required": true,
            "repeats": true
          },
          {
            "extension": [
              {
                "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
                "valueInteger": 10
              }
            ],
            "linkId": "HERF/DE21",
            "text": "Which of the following categories are associated with the event or unsafe condition?",
            "type": "open-choice",
            "required": true,
            "repeats": true,
            "options": {
              "reference": "#d1e6177-vs"
            }
          }
        ]
      },
      {
        "extension": [
          {
            "extension": [
              {
                "url": "#enableWhen.question",
                "valueString": "HERF/DE3"
              },
              {
                "url": "#enableWhen.answer",
                "valueCoding": {
                  "system": "http://ahrq.org/form/question_identifier#HERF/DE3-cs",
                  "code": "A3"
                }
              }
            ],
            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"
          }
        ],
        "linkId": "HERF/SEC01.1",
        "title": "PATIENT INFORMATION (COMPLETE ONLY IF INCIDENT)",
        "text": "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": "MM/DD/YYYY"
              }
            ],
            "linkId": "HERF/DE9a",
            "text": "Event Discovery Date",
            "type": "string",
            "required": true
          },
          {
            "extension": [
              {
                "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-defaultValue",
                "valueCoding": {
                  "system": "HERF/DE9b-cs",
                  "code": "UNK",
                  "display": "Unknown"
                }
              },
              {
                "url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
                "valueString": "HHMM"
              }
            ],
            "linkId": "HERF/DE9b",
            "text": "Event Discovery Time",
            "type": "string",
            "required": true
          }
        ]
      },
      {
        "extension": [
          {
            "extension": [
              {
                "url": "#enableWhen.question",
                "valueString": "HERF/DE3"
              },
              {
                "url": "#enableWhen.answer",
                "valueCoding": {
                  "system": "http://ahrq.org/form/question_identifier#HERF/DE3-cs",
                  "code": "A3"
                }
              }
            ],
            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"
          }
        ],
        "linkId": "HERF/SEC02",
        "title": "Patient Information (COMPLETE ONLY IF INCIDENT):",
        "text": "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": "HERF/DE46",
            "text": "Patient's Name",
            "type": "string",
            "required": true
          },
          {
            "linkId": "HERF/DE47",
            "text": "Patient's Date of Birth",
            "type": "string"
          },
          {
            "linkId": "HERF/DE49",
            "text": "Patient's Medical Record #",
            "type": "string",
            "required": true
          },
          {
            "linkId": "HERF/DE42",
            "text": "Patients' Gender",
            "type": "open-choice",
            "options": {
              "reference": "#d1e6853-vs"
            }
          }
        ]
      },
      {
        "linkId": "HERF/SEC03",
        "title": "Neonatal Patient Information:",
        "text": "COMPLETE ONLY FOR NEONATE AFFECTED BY PERINATAL INCIDENT",
        "question": [
          {
            "linkId": "HERF/Hidden",
            "text": "Is this event a perinatal incident that affected a neonate?",
            "type": "open-choice",
            "options": {
              "reference": "#d1e7006-vs"
            },
            "group": [
              {
                "linkId": "HERF/DE34/A15",
                "required": false,
                "repeats": false,
                "question": [
                  {
                    "linkId": "HERF/DE34",
                    "text": "Neonate's Name",
                    "type": "string"
                  },
                  {
                    "linkId": "HERF/DE37",
                    "text": "Neonate's Date of Birth",
                    "type": "string"
                  },
                  {
                    "linkId": "HERF/DE40",
                    "text": "Neonate's Medical Record #",
                    "type": "string",
                    "required": true
                  },
                  {
                    "linkId": "HERF/DE43",
                    "text": "Neonate's Gender",
                    "type": "open-choice",
                    "required": true,
                    "options": {
                      "reference": "#d1e7220-vs"
                    }
                  }
                ]
              }
            ]
          }
        ]
      },
      {
        "linkId": "HERF/SEC04",
        "title": "REPORT AND EVENT REPORTER INFORMATION",
        "question": [
          {
            "linkId": "HERF/DE33",
            "text": "Anonymous Reporter",
            "type": "open-choice",
            "options": {
              "reference": "#d1e7422-vs"
            },
            "group": [
              {
                "linkId": "HERF/DE33/A18",
                "required": false,
                "repeats": false,
                "question": [
                  {
                    "linkId": "HERF/DE50",
                    "text": "Reporter's Name",
                    "type": "string",
                    "required": true
                  },
                  {
                    "linkId": "HERF/DE52",
                    "text": "Telephone Number",
                    "type": "string",
                    "required": true
                  },
                  {
                    "linkId": "HERF/DE53",
                    "text": "Email Address",
                    "type": "string",
                    "required": true
                  },
                  {
                    "linkId": "HERF/DE36",
                    "text": "Reporter's Job or Position",
                    "type": "string"
                  }
                ]
              }
            ]
          }
        ]
      },
      {
        "linkId": "HERF/SEC05",
        "title": "Thank you for completing these questions.",
        "text": "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."
      },
      {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup",
            "valueCode": "footer"
          }
        ],
        "linkId": "HERF/footer",
        "text": "AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance"
      }
    ]
  }
}