| 74550-5 | Anonymous reporter:Find:Pt:^Event:Ord:AHRQ | optional |
| 74549-7 | Reporter of adverse event or unsafe condition:Pn:Pt:^Event:Nom: | conditional |
| 74548-9 | Reporter phone number:Tele:Pt:^Event:Nom: | conditional |
| 74547-1 | Reporter email:EmailAddr:Pt:^Event:Nom: | conditional |
| 74546-3 | Reporter job or position:Type:Pt:^Event:Nom: | conditional |