diff --git a/resources/seeds/Questionnaire/authorization-for-release-of-medical-images.yaml b/resources/seeds/Questionnaire/authorization-for-release-of-medical-images.yaml index 28a4cae..bd6dbe1 100644 --- a/resources/seeds/Questionnaire/authorization-for-release-of-medical-images.yaml +++ b/resources/seeds/Questionnaire/authorization-for-release-of-medical-images.yaml @@ -3,11 +3,86 @@ resourceType: Questionnaire name: authorization-for-release-of-medical-images title: Authorization for Release of Medical Images status: active +subjectType: + - Patient +launchContext: + - name: + code: Patient + type: + - Patient item: - - linkId: question-1 - text: Question 1 + - text: '**Authorization to Use and Disclose Protected Health Information**' + type: display + linkId: AOjGTi2c + - text: >- + **Research Study Title: **Elucidating the Impact of Social Wellness and + Artificial Intelligence on the Psychological Consequences of Breast Cancer + Imaging + type: display + linkId: researchStudyTitle + - text: 'Principal Investigator: Dexter Hadley, MD, PhD' + type: display + linkId: principalInvestigator + - text: 'Co-Investigator: Amoy Fraser, PhD' + type: display + linkId: coInvestigator + - text: Name of Research Participant type: string - required: true + linkId: participantName + - text: Date of Birth + type: date + linkId: dateOfBirth + - text: Street Address + type: string + linkId: streetAddress + - text: City, State & Zip Code + type: string + linkId: cityStateZip + - text: >- + By signing this form, I voluntarily authorize ____________________________ + to release my radiographic breast cancer imaging and related health + information taken on or + type: string + linkId: authorizationRelease + - text: >- + about_____________________ (approximate dates of imaging) to University of + Central Florida. + type: date + linkId: useForResearch + - text: >- + By signing this form, I voluntarily authorize, give my permission and + allow use and disclosure of my radiographic breast cancer imaging and + related health information. The radiographic breast cancer images will be + used for research purposes as described in the Informed Consent Form for + the above research study title. This authorization will remain in effect + until described in the Informed Consent Form for the above research study + title. + type: display + linkId: authorizationEffect + - text: >- + I have read all pages of this form and agree to the disclosures above from + the types of sources listed. + type: boolean + linkId: readAgreeDisclosure + - text: >- + Print Name of Participant or Participant’s Legal Representative (if + applicable) + type: string + linkId: printName + - text: Signature of Participant or Participant’s Legal Representative + type: string + linkId: signature + - text: 'Date Signed ' + type: date + linkId: dateSigned + - text: PatientId + type: string + hidden: true + linkId: patientId + initialExpression: + language: text/fhirpath + expression: '%Patient.id' + meta: profile: - https://beda.software/beda-emr-questionnaire