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the_basics_questionnaire.json
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{
"resourceType": "Questionnaire",
"identifier": [
{
"value": "Vibrent_FORM_ID_284"
}
],
"version": "V2022.11.17",
"status": "published",
"date": "2023-03-28T14:07:28+00:00",
"group": {
"linkId": "root_group",
"title": "The Basics",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "TheBasics"
}
],
"required": true,
"repeats": false,
"question": [
{
"linkId": "5690",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "TheBasics_Birthplace"
}
],
"text": "In what country were you born?",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "\u00bfEn qu\u00e9 pa\u00eds naci\u00f3 usted?"
}
]
}
]
},
"type": "choice",
"repeats": false,
"option": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "Birthplace_USA",
"display": "USA",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Estados Unidos"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "PMI_Other",
"display": "Other",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Otro pa\u00eds"
}
]
}
]
}
}
]
},
{
"linkId": "5691",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "TheBasics_CountryBornTextBox"
}
],
"text": "country of origin",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "pa\u00eds de origen"
}
]
}
]
},
"type": "text",
"repeats": false
},
{
"linkId": "5696",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "Race_WhatRaceEthnicity"
}
],
"text": "Which categories describe you? Select all that apply. Note, you may select more than one group.",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "\u00bfQu\u00e9 categor\u00edas lo o la describen?\nMarque todas las respuestas que correspondan. Nota: puede seleccionar m\u00e1s de un grupo."
}
]
}
]
},
"type": "choice",
"repeats": true,
"option": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_AIAN",
"display": "American Indian or Alaska Native (For example: Aztec, Blackfeet Tribe, Mayan, Navajo Nation, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc.)",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Indio Americano o Nativo de Alaska (por ejemplo, Navajo Nation, Blackfeet Tribe, Maya, Azteca, Native Village of Barrow Inupiat, Nome Eskimo Community, etc)"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_Asian",
"display": "Asian (For example: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, etc.) ",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Asi\u00e1tico (por ejemplo, Chino, Filipino, Indio Asi\u00e1tico, Vietnamita, Coreano, Japon\u00e9s, etc.)"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_Black",
"display": "Black, African American or African (For example: African American, Ethiopian, Haitian, Jamaican, Nigerian, Somali, etc.)",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Negro, Africano, o Afroamericano (por ejemplo, Africano Americano, Jamaiquino, Haitiano, Nigeriano, Et\u00edope, Somal\u00ed, etc.)"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_Hispanic",
"display": "Hispanic, Latino, or Spanish (For example: Colombian, Cuban, Dominican, Mexican or Mexican American, Puerto Rican, Salvadoran, etc.)",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Hispano, Latino o Espa\u00f1ol (por ejemplo, Mexicano, Mexicano Americano, Puertorrique\u00f1o, Cubano, Salvadore\u00f1o, Dominicano, Colombiano, etc.)"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_MENA",
"display": "Middle Eastern or North African (For example: Algerian, Egyptian, Iranian, Lebanese, Moroccan, Syrian, etc.)",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Del Medio Oriente o del Norte de \u00c1frica (por ejemplo, Liban\u00e9s, Iran\u00ed, Egipcio, Sirio, Marroqu\u00ed, Argelino, etc.)"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_NHPI",
"display": "Native Hawaiian or other Pacific Islander (For example: Chamorro, Fijian, Marshallese, Native Hawaiian, Tongan, etc.) ",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Nativo de Haw\u00e1i o de otras Islas del Pac\u00edfico (por ejemplo, Nativo Hawaiano, Samoano, Chamorro, Tongano, Fiyiano, Marshal\u00e9s, etc.)"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_White",
"display": "White (For example: English, European, French, German, Irish, Italian, Polish, etc.)",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Blanco (por ejemplo, Alem\u00e1n, Europeo, Irland\u00e9s, Ingl\u00e9s, Italiano, Polaco, Franc\u00e9s, etc.)"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatRaceEthnicity_RaceEthnicityNoneOfThese",
"display": "None of these fully describe me",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Ninguna de estas me describe completamente"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "PMI_PreferNotToAnswer",
"display": "Prefer not to answer\n",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Prefiero no responder"
}
]
}
]
}
}
]
},
{
"linkId": "9825",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "RaceEthnicityNoneOfThese_RaceEthnicityFreeTextBox"
}
],
"text": "enter other race or ethnicity",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "ingrese otra raza u origen \u00e9tnico"
}
]
}
]
},
"type": "text",
"repeats": false
},
{
"linkId": "9788",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AIAN_AIANSpecific"
}
],
"text": "American Indian or Alaska Native",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Ind\u00edgena estadounidense"
}
]
}
]
},
"type": "choice",
"repeats": true,
"option": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AIANSpecific_AmericanIndian",
"display": "American Indian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Indio americano"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AIANSpecific_AlaskaNative",
"display": "Alaska Native",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Nativo de Alaska"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AIANSpecific_CentralSouthAmericanIndian",
"display": "Central or South American Indian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Indio centroamericano o sudamericano"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AIANSpecific_AIANNoneOfTheseDescribeMe",
"display": "None of these fully describe me",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Ninguna de estas me describe completamente"
}
]
}
]
}
}
]
},
{
"linkId": "9795",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "WhatTribeAffiliation_FreeText"
}
],
"text": "enter tribe or tribal descent",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "escriba tribu u origen tribal"
}
]
}
]
},
"type": "text",
"repeats": false
},
{
"linkId": "10788",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AIANNoneOfTheseDescribeMe_AIANFreeText"
}
],
"text": "Enter other race or ethnicity",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Ingrese otra raza u origen \u00e9tnico"
}
]
}
]
},
"type": "text",
"repeats": false
},
{
"linkId": "9803",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "Asian_AsianSpecific"
}
],
"text": "Asian ",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Asi\u00e1tico"
}
]
}
]
},
"type": "choice",
"repeats": true,
"option": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_AsianSpecificIndian",
"display": "Asian Indian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Indio asi\u00e1tico"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Cambodian",
"display": "Cambodian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Camboyano"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Chinese",
"display": "Chinese",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Chino"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Filipino",
"display": "Filipino",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Filipino"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Hmong",
"display": "Hmong",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Hmong"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Japanese",
"display": "Japanese",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Japon\u00e9s"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Korean",
"display": "Korean",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Coreano"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Pakistani",
"display": "Pakistani",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Pakistan\u00ed"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_Vietnamese",
"display": "Vietnamese",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Vietnamita"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "AsianSpecific_NoneOfTheseDescribeMe",
"display": "None of these fully describe me",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Ninguna de estas me describe completamente"
}
]
}
]
}
}
]
},
{
"linkId": "9804",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "NoneOfTheseDescribeMe_AsianFreeText"
}
],
"text": "enter other race or ethnicity",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "ingrese otra raza u origen \u00e9tnico"
}
]
}
]
},
"type": "text",
"repeats": false
},
{
"linkId": "9807",
"concept": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "Black_BlackSpecific"
}
],
"text": "Black, African American or African",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Negro o afroamericano"
}
]
}
]
},
"type": "choice",
"repeats": true,
"option": [
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "BlackSpecific_AfricanAmerican",
"display": "African American",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Afroamericano"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "BlackSpecific_Barbadian",
"display": "Barbadian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Barbade\u00f1o"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "BlackSpecific_Caribbean",
"display": "Caribbean",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Caribe"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "BlackSpecific_Ethiopian",
"display": "Ethiopian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Et\u00edope"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "BlackSpecific_Ghanaian",
"display": "Ghanaian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Ghan\u00e9s"
}
]
}
]
}
},
{
"system": "http://terminology.pmi-ops.org/CodeSystem/ppi",
"code": "BlackSpecific_Haitian",
"display": "Haitian",
"_display": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [
{
"url": "lang",
"valueCode": "es"
},
{
"url": "content",
"valueString": "Haitiano"
}
]
}
]