Form Structure: Traumatic Life Events Questionnaire

Short Name:
TLEQ
Description:
Traumatic Life Events Questionnaire (TLEQ) is to identify important life experiences that can affect a person's emotional well-being or later quality of life.
Disease:
Traumatic Brain Injury
Required Program Form:
No
Standardization:
Standard
Publication Date:
2022-07-20
Version:
1.0
Date Created:
2022-07-20
Created By:
Number of Data Elements:
65
eForms:
N

Attached Data Elements

# Title Short Description Variable Name Required? Type
1 GUID   Global Unique ID which uniquely identifies a subject GUID Required CDE
2 Subject identifier number   An identification number assigned to the participant/subject within a given protocol or a study. SubjectIDNum Optional CDE
3 Age in years   Value for participant's subject age recorded in years. AgeYrs Recommended CDE
4 Vital status   Status of participant/subject as alive or dead VitStatus Optional CDE
5 Visit date   Actual interview or visit date VisitDate Recommended CDE
6 Site name   The name of the site for the study SiteName Recommended CDE
7 Days since baseline   The number of days since baseline DaysSinceBaseline Optional CDE
8 Case control indicator   Indicator of whether subject is in the case or control arm of the study. CaseContrlInd Optional CDE
9 General notes text   General notes GeneralNotesTxt Optional CDE

Additional Element Groups

Listed below are your additional element groups.

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Form Administration (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Language form administration ISO code  Code (ISO 639-2) for the language that was used for CRF/instrument/scale/etc. administration LangCRFAdministratISOCode Recommended CDE
2 Language form administration ISO code other text  The free-text field related to 'Language used for CRF/instrument/scale/etc. administration ISO code' specifying other text. LangCRFAdministratISOCodeOTH Recommended CDE
3 Context type  The context to which the questions were answered ContextType Recommended CDE
4 Context type other text  The free-text related to ContextType specifying other text ContextTypeOTH Recommended CDE
5 Data source  Source of the data provided on the case report form DataSource Recommended CDE
6 Data source other text  The free-text field related to Data source specifying other text. Source of the data provided on the case report form DataSourceOTH Recommended CDE
7 Assessment completion status  Status of completion of an assessment, such as a case report from (CRF), instrument, scale, computer assessment, etc. AssessmentCompletionStat Recommended CDE
8 Assessment completion status text  A free text related to Assessment completion status specifying completion details. This data element should be used along with AssessmenttCompletionStat to further describe the status of assessment completion AssessmentCompletionStatTxt Recommended CDE

TLEQ (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Traumatic Life Events Questionnaire - Natural disaster indicator  Indicator as to whether the subject experienced a natural disaster, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQNaturalDisasterInd Recommended UDE
2 Traumatic Life Events Questionnaire - Fear from natural disaster indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when a natural disaster happened, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromNaturlDisastrInd Recommended UDE
3 Traumatic Life Events Questionnaire - Serious motor vehicle accident indicator  Indicator as to whether the subject was involved in a motor vehicle accident where the subject received medical attention or that badly injured or killed someone, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSeriousMotorVehlAccdntInd Recommended UDE
4 Traumatic Life Events Questionnaire - Fear from motor vehicle accident indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the motor vehicle accident happend, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromMotorVehclAccdtInd Recommended UDE
5 Traumatic Life Events Questionnaire - Other accident that someone was hurt indicator  Indicator as to whether the subject was involved in any other kind of accident where the subject or someone else was badly hurt, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQOthrAccdtSomeoneHurtInd Recommended UDE
6 Traumatic Life Events Questionnaire - Fear from any other accident indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when any other kind of accident happened, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromAnyOthrAccdntInd Recommended UDE
7 Traumatic Life Events Questionnaire - War zone indicator  Indicator as to whether the subject lived, worked, or had military service in a war zone, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQWarZoneInd Recommended UDE
8 Traumatic Life Events Questionnaire - Exposed to combat indicator  Indicator as to whether the subject was ever exposed to warfare or combat, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQExposedToCombatInd Recommended UDE
9 Traumatic Life Events Questionnaire - Fear from warfare indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when exposed to warfare or combat, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromWarfareInd Recommended UDE
10 Traumatic Life Events Questionnaire - Death of loved one indicator  Indicator as to whether the subject experienced the sudden and unexpected death of a close friend or loved one, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQDeathOfLovedOneInd Recommended UDE
11 Traumatic Life Events Questionnaire - Fear from death of loved one indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the subject experienced the sudden and unexpected death of a close friend or loved one, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromDeathOfLovedOneInd Recommended UDE
12 Traumatic Life Events Questionnaire - Survived life threatening accident indicator  Indicator as to whether the subject survived a life threatening or permanently disabling accident, assault, or illness, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSurvivLifeThrtningAccdtInd Recommended UDE
13 Traumatic Life Events Questionnaire - Fear from life threatening accident indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when a loved one survived a life threatening or permanently disabling accident, assault, or illness, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromLifeThrtnAccdtInd Recommended UDE
14 Traumatic Life Events Questionnaire - Life threatening illness indicator  Indicator as to whether the subject experienced a life threatening illness, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQLifeThreateningIllnessInd Recommended UDE
15 Traumatic Life Events Questionnaire - Fear from life threatening illness indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the subject experienced a life threatening illness, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromLifeThrtnIllnesInd Recommended UDE
16 Traumatic Life Events Questionnaire - Robbed with a weapon indicator  Indicator as to whether the subject was robbed or was present during a robbery where the robber(s) used or displayed a weapon, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQRobbedWithWeaponInd Recommended UDE
17 Traumatic Life Events Questionnaire - Fear being robbed indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the subject was robbed or was present during a robbery wher the robber(s) used or displayed a weapon, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearBeingRobbedInd Recommended UDE
18 Traumatic Life Events Questionnaire - Hurt by stranger indicator  Indicator as to whether the subject has been hit or beaten up and badly hurt by a stranger or by someone they didn't know very well, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQHurtByStrangerInd Recommended UDE
19 Traumatic Life Events Questionnaire - Fear being hurt by stranger indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the subject was hit or beaten up and badly hurt by a stranger or by someone they didn't know very well, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearBeingHurtByStrangerInd Recommended UDE
20 Traumatic Life Events Questionnaire - Seen stranger kill indicator  Indicator as to whether the subject has seen a stranger (or someone they didn't know very well) attack or beat up someone and seriously injure or kill them, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSeenStrangerKillInd Recommended UDE
21 Traumatic Life Events Questionnaire - Fear from seeing a stranger kill indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the subject saw a stranger attack or beat up someone and seriously injure or kill them, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromSeeStrngerKillInd Recommended UDE
22 Traumatic Life Events Questionnaire - Threatened to be killed indicator  Indicator as to whether someone threatened to kill the subject or cause the subject serious physical harm, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQThreatenedToBeKilledInd Recommended UDE
23 Traumatic Life Events Questionnaire - Fear from threatened to be killed indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when someone threatened to kill the subject or cause the subject serious physical harm, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromThrtnedBeKilledInd Recommended UDE
24 Traumatic Life Events Questionnaire - Bruises from punishment indicator  Indicator as to whether the subject was physically punished while growing up in a way that resulted in bruises, burns, cuts, or broken bones, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQBruisesFromPunishmentInd Recommended UDE
25 Traumatic Life Events Questionnaire - Fear bruises from punishment indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when growing up the subject was physically punished in a way that resulted in serious injuries, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearBruisesFromPunshmntInd Recommended UDE
26 Traumatic Life Events Questionnaire - Seen family violence indicator  Indicator as to whether the subject seen or heard family violence while growing up, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSeenFamViolenceInd Recommended UDE
27 Traumatic Life Events Questionnaire - Fear from family violence indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when growing up seeing and hearing family violence, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromFamViolenceInd Recommended UDE
28 Traumatic Life Events Questionnaire - Physical abuse by partner indicator  Indicator as to whether the subject has been slapped, punched, kicked, beaten up, or otherwise physically hurt by your spouse, a boyfriend/girlfriend, or some other intimate partner, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQPhyAbusByPrtnrInd Recommended UDE
29 Traumatic Life Events Questionnaire - Fear from physical abuse by partner indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when slapped, punched, kicked, beaten up, or otherwise physically hurt by intimate partner, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromPhyAbusByPrtnrInd Recommended UDE
30 Traumatic Life Events Questionnaire - Sexual abuse as a minor indicator  Indicator as to whether the subject was touched or fondled in a sexual way or made to touch or fondle someone else's body in a sexual way before their 13th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSexualAbuseAsMinorInd Recommended UDE
31 Traumatic Life Events Questionnaire - Fear from sexual abuse as a minor indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when touched or fondled in a sexual way before their 13th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromSexAbusAsMinorInd Recommended UDE
32 Traumatic Life Events Questionnaire - Sexual touch with no consent as a minor indicator  Indicator as to whether the subject experienced someone touching sexual parts of their body against their will or without their consent before their 13th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSexulTuchNoCnsntAsMinorInd Recommended UDE
33 Traumatic Life Events Questionnaire - Fear from sexual touch as a minor indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when someone touched sexual parts of their body without their consent before their 13th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromSexulTuchAsMinrInd Recommended UDE
34 Traumatic Life Events Questionnaire - Sexual touch with no consent as a teen indicator  Indicator as to whether the subject experienced someone touching sexual parts of their body against their will or without their consent after their 13th birthday and before their 18th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSexulTuchNoConsntAsTeenInd Recommended UDE
35 Traumatic Life Events Questionnaire - Fear from sexual touch as a teen indicator  Indicator as to whether the subject experienced intense fear when someone touched sexual parts of their body without their consent after their 13th birthday and before their 18th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromSexTouchAsTeenInd Recommended UDE
36 Traumatic Life Events Questionnaire - Sexual touch with no consent as adult indicator  Indicator as to whether the subject experienced someone touching sexual parts of their body against their will or without their consent after their 18th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSexulTuchNoCnsntAsAdultInd Recommended UDE
37 Traumatic Life Events Questionnaire - Fear from sexual touch as adult indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when someone touched sexual parts of their body without their consent after their 18th birthday, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromSexTouchAsAdultInd Recommended UDE
38 Traumatic Life Events Questionnaire - Unwanted sexual attention indicator  Indicator as to whether the subject was ever subjected to uninvited or unwanted sexual attention, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQUnwantedSexualAttnInd Recommended UDE
39 Traumatic Life Events Questionnaire - Fear from unwanted sexual attention indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when subjected to uninvited or unwanted sexual attention, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromUnwantedSexAttnInd Recommended UDE
40 Traumatic Life Events Questionnaire - Stalked indicator  Indicator as to whether the subject was stalked, followed or kept track of the subject's activities causing the subject to feel intimidated or concerned for their safety, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQStalkedInd Recommended UDE
41 Traumatic Life Events Questionnaire - Fear from being stalked indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when stalked causing the subject to feel intimidated or concerned for their safety, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromBeingStalkedInd Recommended UDE
42 Traumatic Life Events Questionnaire - Miscarriage indicator  Indicator as to whether the subject or the subject's romantic partner ever experienced a miscarriage, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQMiscarriageInd Recommended UDE
43 Traumatic Life Events Questionnaire - Fear from having miscarriage indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the subject or the subject's romantic partner experienced a miscarriage, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromHvingMiscarrgeInd Recommended UDE
44 Traumatic Life Events Questionnaire - Abortion indicator  Indicator as to whether the subject or the subject's romantic partner ever had an abortion, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQAbortionInd Recommended UDE
45 Traumatic Life Events Questionnaire - Fear from having abortion indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror when the subject or the subject's romantic partner experienced an abortion, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromHavingAbortionInd Recommended UDE
46 Traumatic Life Events Questionnaire - Serious life events indicator  Indicator as to whether the subject experienced or seen any other events that were life threatening, caused serious injury, or were highly disturbing or distressing, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQSeriousLifeEventsInd Recommended UDE
47 Traumatic Life Events Questionnaire - Fear from serious life events indicator  Indicator as to whether the subject experienced intense fear, helplessness, or horror from any other events that were life threatening, caused serious injury, or were highly disturbing, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQFearFromSeriousLifeEvntInd Recommended UDE
48 Traumatic Life Events Questionnaire - Distressing event type  Type of distressing event for the subject, as part of the Traumatic Life Events Questionnaire (TLEQ). TLEQDistressingEventTyp Recommended UDE