<?xml version="1.0" encoding="UTF-8"?>
<!--
  ILLUSTRATIVE ONLY — not a live MAH case; not for EDA filing.
  AllesEra / QPPV Agent sample pack (#537). Shape resembles E2B(R3) elements;
  values are fictional.
-->
<MCCI_IN200100UV01 xmlns="urn:hl7-org:v3" ITSVersion="XML_1.0">
  <id root="2.16.840.1.113883.3.989.2.1.3.22" extension="ILLUSTRATIVE-ICSR-0001"/>
  <creationTime value="20260315"/>
  <interactionId root="2.16.840.1.113883.1.6" extension="MCCI_IN200100UV01"/>
  <PORR_IN049016UV>
    <id root="2.16.840.1.113883.3.989.2.1.3.1" extension="ILLUSTRATIVE-ICSR-0001"/>
    <effectiveTime value="20260315"/>
    <component>
      <adverseEventAssessment>
        <subject1>
          <primaryRole>
            <player1>
              <!-- De-identified illustration: age band only -->
              <name>ILLUSTRATIVE PATIENT</name>
            </player1>
          </primaryRole>
        </subject1>
        <component>
          <causalityAssessment>
            <code code="1" codeSystem="2.16.840.1.113883.3.989.2.1.1.19" displayName="Related"/>
          </causalityAssessment>
        </component>
      </adverseEventAssessment>
    </component>
  </PORR_IN049016UV>
</MCCI_IN200100UV01>
