Notice
- Important: This guidance is under active development by NHS England and content may be added or updated on a regular basis.
- This Implementation Guide is currently in Draft and SHOULD NOT be used for development or active implementation without express direction from the NHS England Genomics Unit.
QuestionnaireResponse-RoD-PheobeSmithamCDForn-Example
Example of a filled Consultee Declaration Form.
| QuestionnaireResponse |
| id : QuestionnaireResponse-RoD-PheobeSmithamCDForn-Example |
| questionnaire : https://fhir.nhs.uk/Questionnaire/Questionnaire-RoD-ConsulteeDeclarationForm-Example |
| status : completed |
| basedOn |
| reference : ServiceRequest/ServiceRequest-WGSTestOrderForm-TrioTestingProband-Example |
| subject |
| reference : Patient/Patient-PheobeSmitham-Example |
| identifier |
| system : https://fhir.nhs.uk/Id/nhs-number |
| value : 9449307539 |
| display : A Patient |
| authored : 2023-09-15 |
| author |
| type : PractitionerRole |
| identifier |
| system : https://fhir.nhs.uk/Id/sds-role-profile-id |
| value : 999999999999 |
| source |
| type : RelatedPerson |
| reference : RelatedPerson/RelatedPerson-AliceSmithamProbandMother-Example |
| identifier |
| system : https://fhir.nhs.uk/Id/nhs-number |
| value : 9449307246 |
| item |
| linkId : patientDetails |
| text : Patient Details |
| item |
| linkId : givenName |
| text : First Name |
| answer |
| value : Phoebe |
| item |
| linkId : familyName |
| text : Last Name |
| answer |
| value : Smitham |
| item |
| linkId : nhs_Number |
| text : NHS number (or postcode if not not known) |
| answer |
| value : 9449307539 |
| item |
| linkId : birthDate |
| text : Date of Birth |
| answer |
| value : 2013-09-27 |
| item |
| linkId : confirmationOfDecision |
| text : Confirmation of decision |
| item |
| linkId : confirmation |
| text : I confirm that I have read and had the opportunity to discuss information about acting as a consultee for the person lacking capacity. My research choices are indicated below. |
| item |
| linkId : choiceConfirmation1 |
| text : I have been consulted about this person’s participation in the National Genomic Research Library |
| answer |
| value : True |
| item |
| linkId : choiceConfirmation2 |
| text : I am willing to accept the role of consultee for this person |
| answer |
| value : True |
| item |
| linkId : isRemoteConsentTrue |
| text : Consent obtained remotely, no consultee signature |
| answer |
| value : True |
| item |
| item |
| linkId : consulteeNamecombined |
| answer |
| value : Alice Smith |
| item |
| linkId : dateConsulteeCompletedForm |
| answer |
| value : 2023-09-15 |
| linkId : consulteeValidation |
| text : Consultee Validation |
| item |
| linkId : healthcareProfessionalValidation |
| text : Healthcare professional use only |
| item |
| linkId : healthcareProfessional |
| text : To be completed by the healthcare professional recording the consultee’s choices. |
| item |
| linkId : healthcareProfessionalName |
| text : Healthcare professional name |
| answer |
| value : Dr. Eugene Smith |
| item |
| linkId : healthcareProfessionalSignature |
| text : Signature |
| answer |
| value : EugeneSmith |
| item |
| linkId : datehealthcareProfessionalCompletedForm |
| text : Date |
| answer |
| value : 2023-09-15 |
{
"questionnaire": "https://fhir.nhs.uk/Questionnaire/Questionnaire-RoD-ConsulteeDeclarationForm-Example",
],
},
},
}
},
}
},
{
{
},
{
},
{
]
},
{
}
]
},
{
{
"text": "I confirm that I have read and had the opportunity to discuss information about acting as a consultee for the person lacking capacity. My research choices are indicated below.",
{
"text": "I have been consulted about this person’s participation in the National Genomic Research Library",
]
},
{
]
}
]
}
]
},
{
]
},
{
{
},
{
}
],
},
{
{
{
]
},
{
]
},
{
]
}
]
}
]
}
]
}
</basedOn>
<questionnaire value="https://fhir.nhs.uk/Questionnaire/Questionnaire-RoD-ConsulteeDeclarationForm-Example" />
</identifier>
</subject>
</identifier>
</author>
</identifier>
</source>
</answer>
</item>
</answer>
</item>
</answer>
</item>
</answer>
</item>
</item>
<text value="I confirm that I have read and had the opportunity to discuss information about acting as a consultee for the person lacking capacity. My research choices are indicated below." />
<text value="I have been consulted about this person’s participation in the National Genomic Research Library" />
</answer>
</item>
</answer>
</item>
</item>
</item>
</answer>
</item>
</item>
</answer>
</item>
</item>
</answer>
</item>
</answer>
</item>
</answer>
</item>
</item>
</item>
</QuestionnaireResponse>