{
  "description": "This questionnaire is to be used to document the patient consent for young person(ages 6 – 15) before undergoing Genomic testing and their choice of participation in the National Genomic Research Library programme",
  "_filename": "examples/Questionnaire-RoD-YoungPersonAssentForm-Example.json",
  "package_name": "uk.nhsengland.genomics.r4",
  "subjectType": [ "Patient" ],
  "date": "2024-01-18T09:00:00Z",
  "publisher": "NHS England",
  "purpose": "Young Person Assent Form (ages 6 – 15) Regarding Genomic Testing",
  "name": "QuestionnaireRoDYoungPersonAssentFormExample",
  "item": [ {
    "text": "Feel free to ask any questions before answering the questions below.",
    "type": "display",
    "linkId": "declaration"
  }, {
    "item": [ {
      "text": "First Name",
      "type": "string",
      "linkId": "givenName",
      "required": true
    }, {
      "text": "Last Name",
      "type": "string",
      "linkId": "familyName",
      "required": true
    }, {
      "text": "NHS number (or postcode if not not known)",
      "type": "string",
      "linkId": "nhs_Number",
      "required": true
    }, {
      "text": "Date of Birth",
      "type": "date",
      "linkId": "birthDate",
      "required": true
    } ],
    "text": "Patient Details",
    "type": "group",
    "linkId": "patientDetails"
  }, {
    "item": [ {
      "text": "1. Have you read information or has someone explained the research to you?",
      "type": "boolean",
      "linkId": "consentQuestion1",
      "required": true
    }, {
      "text": "2. Have you asked all the questions you want?",
      "type": "boolean",
      "linkId": "consentQuestion2",
      "required": true
    }, {
      "text": "3. Have you had your questions answered in a way you understand?",
      "type": "boolean",
      "linkId": "consentQuestion3",
      "required": true
    }, {
      "text": "4. Do you understand it’s OK to say you don’t want to take part – but that your parent(s), or guardian who look after you, will make the final choice?",
      "type": "boolean",
      "linkId": "consentQuestion4",
      "required": true
    }, {
      "text": "5. Are you happy to take part?",
      "type": "boolean",
      "linkId": "consentQuestion5",
      "required": true
    } ],
    "text": "Please indicate your choices below by ticking the appropriate box:",
    "type": "group",
    "linkId": "declarationResponse",
    "readOnly": true
  }, {
    "item": [ {
      "text": "• Don’t sign your name on this form",
      "type": "display",
      "linkId": "NonWillingToConsent1"
    }, {
      "text": "• Tell your parents and healthcare team how you feel, so they know",
      "type": "display",
      "linkId": "NonWillingToConsent2"
    } ],
    "text": "If ANY of your answers are ‘NO’, or you don’t want to take part:",
    "type": "group",
    "linkId": "guidanceNonWillingToConsent"
  }, {
    "item": [ {
      "text": "• Please write your name, signature, and today’s date here:",
      "type": "display",
      "linkId": "WillingToConsent"
    } ],
    "text": "If ALL of your answers are ‘YES’:",
    "type": "group",
    "linkId": "guidanceWillingToConsent"
  }, {
    "text": "Assent obtained remotely, no participant signature",
    "type": "boolean",
    "linkId": "isRemoteConsentTrue",
    "required": true
  }, {
    "item": [ {
      "text": "Patient Name",
      "type": "string",
      "linkId": "patientNamecombined",
      "required": true
    }, {
      "text": "Signature",
      "type": "string",
      "linkId": "patientSignature",
      "required": true
    }, {
      "text": "Date",
      "type": "dateTime",
      "linkId": "datePatientCompletedForm",
      "required": true
    } ],
    "text": "Patient Validation",
    "type": "group",
    "linkId": "patientValidation",
    "enableWhen": [ {
      "operator": "=",
      "question": "consentQuestion1",
      "answerBoolean": true
    }, {
      "operator": "=",
      "question": "consentQuestion2",
      "answerBoolean": true
    }, {
      "operator": "=",
      "question": "consentQuestion3",
      "answerBoolean": true
    }, {
      "operator": "=",
      "question": "consentQuestion4",
      "answerBoolean": true
    }, {
      "operator": "=",
      "question": "consentQuestion5",
      "answerBoolean": true
    }, {
      "operator": "=",
      "question": "isRemoteConsentTrue",
      "answerBoolean": false
    } ],
    "enableBehavior": "all"
  } ],
  "type": null,
  "experimental": null,
  "resourceType": "Questionnaire",
  "title": "National Genomic Research Library Young Person Assent Form (ages 6 – 15)",
  "package_version": "0.4.0-prerelease",
  "status": "draft",
  "id": "2367b0b4-e480-4e56-af0d-d06f447ba5b4",
  "kind": null,
  "url": "https://fhir.nhs.uk/Questionnaire/Questionnaire-RoD-YoungPersonAssentForm-Example",
  "version": "0.1.0",
  "contact": [ {
    "name": "NHS England",
    "telecom": [ {
      "use": "work",
      "rank": 1,
      "value": "interoperabilityteam@nhs.net",
      "system": "email"
    } ]
  } ]
}