Form Structure: Concussion Clinical Profiles Screening (CCPS)
This form structure is an organized set of data definitions for a form that has not been copyrighted
Resource:
FITBIR
Title:
Concussion Clinical Profiles Screening (CCPS)
Short Name:
CCPS
Description:
CP-Screen is a 29-item self-report, clinical profiles-based symptom inventory that measures five concussion clinical profiles: 1) anxiety/mood, 2) cognitive/fatigue, 3) migraine, 4) ocular, 5) vestibular; and two modifying factors: 1) sleep, 2) neck. Participants indicate on a scale of 0-none to 3-severe the level of symptom severity for each item. The CP-Screen yields average factor and modifier scores, with higher scores indicative of worse symptom severity. The CP-Screen takes 3-5 minutes to complete.
Kontos AP, Elbin RJ, Trbovich A, Womble M, Said A, Sumrok VF, French J, Kegel N, Puskar A, Sherry N, Holland C, Collins M. Concussion Clinical Profiles Screening (CP Screen) Tool: Preliminary Evidence to Inform a Multidisciplinary Approach. Neurosurgery. 2020 Aug 1;87(2):348-356. doi: 10.1093/neuros/nyz545. PMID: 31950187.
Disease:
Traumatic Brain Injury
Required Program Form:
No
Standardization:
Standard
Labels:
Form Type:
Clinical Assessment
Publication Date:
2021-09-20
Version:
1.0
Date Created:
2021-09-10
Owner:
Number of Data Elements:
61
eForms:
N
Logically grouped data elements with defined frequency at which they repeat.
| # | 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.
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 |
CP SCREEN (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Concussion Clinical Profiles Screening (CCPS) - Feeling sad scale | Scale of feeling sad, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSFeelingSadScl | Recommended | UDE |
| 2 | Concussion Clinical Profiles Screening (CCPS) - Headache when wake up scale | Scale of headache when wake up, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSHeadachWkUpScl | Recommended | UDE |
| 3 | Concussion Clinical Profiles Screening (CCPS) - Difficulty or headache when looking at screen scale | Scale of difficulty or headache when looking at screen, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSDiffHeadachLkScreenScl | Recommended | UDE |
| 4 | Concussion Clinical Profiles Screening (CCPS) - Dizziness when move head scale | Scale of dizziness when move head, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSDizzMvHeadScl | Recommended | UDE |
| 5 | Concussion Clinical Profiles Screening (CCPS) - Difficulty turning off thoughts scale | Scale of difficulty turning off thoughts, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSDiffTrnOffThgtsScl | Recommended | UDE |
| 6 | Concussion Clinical Profiles Screening (CCPS) - Headache with nausea scale | Scale of headache with nausea scale, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSHeadachNausScl | Recommended | UDE |
| 7 | Concussion Clinical Profiles Screening (CCPS) - Trouble focusing eyes while reading scale | Scale of trouble focusing eyes while reading, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSTrblFocEyesReadngScl | Recommended | UDE |
| 8 | Concussion Clinical Profiles Screening (CCPS) - Frontal headache scale | Scale of frontal headache, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSFrntlHeadacheScl | Recommended | UDE |
| 9 | Concussion Clinical Profiles Screening (CCPS) - Difficulty or discomfort in busy environments scale | Scale of difficulty or discomfort in busy environments, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSDiffDiscmfrtBsyEnvScl | Recommended | UDE |
| 10 | Concussion Clinical Profiles Screening (CCPS) - Constantly thinking about your symptoms scale | Scale of constantly thinking about your symptoms, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSCnstntThnkSymptsScl | Recommended | UDE |
| 11 | Concussion Clinical Profiles Screening (CCPS) - Headache with sensitivity to light or noise scale | Scale of headache with sensitivity to light or noise, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSHeadachSensLghtNoiseScl | Recommended | UDE |
| 12 | Concussion Clinical Profiles Screening (CCPS) - Feeling motion sick scale | Scale of feeling motion sick, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSFeelngMotionSickScl | Recommended | UDE |
| 13 | Concussion Clinical Profiles Screening (CCPS) - Feeling more tired at end of day scale | Scale of feeling more tired at end of day, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSFeelngMorTrdEndDayScl | Recommended | UDE |
| 14 | Concussion Clinical Profiles Screening (CCPS) - Blurry or double vision scale | Scale of blurry or double vision, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSBlurryDblVisScl | Recommended | UDE |
| 15 | Concussion Clinical Profiles Screening (CCPS) - Lightheadedness scale | Scale of lightheadedness, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSLightheadednessScl | Recommended | UDE |
| 16 | Concussion Clinical Profiles Screening (CCPS) - Neck pain or stiffness scale | Scale of neck pain or stiffness, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSNeckPainStiffScl | Recommended | UDE |
| 17 | Concussion Clinical Profiles Screening (CCPS) - Sleeping more scale | Scale of sleeping more, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSSleepngMoreScl | Recommended | UDE |
| 18 | Concussion Clinical Profiles Screening (CCPS) - Sleeping less scale | Scale of sleeping less, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSSleepngLessScl | Recommended | UDE |
| 19 | Concussion Clinical Profiles Screening (CCPS) - Eye strain during visual activity scale | Scale of eye strain during visual activity, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSEyeStrainDurVisActScl | Recommended | UDE |
| 20 | Concussion Clinical Profiles Screening (CCPS) - Visual aura scale | Scale of visual aura, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSVisAuraScl | Recommended | UDE |
| 21 | Concussion Clinical Profiles Screening (CCPS) - Vertigo scale | Scale of vertigo, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSVertigoScl | Recommended | UDE |
| 22 | Concussion Clinical Profiles Screening (CCPS) - Difficulty falling asleep scale | Scale of difficulty falling asleep, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSDiffFallSleepScl | Recommended | UDE |
| 23 | Concussion Clinical Profiles Screening (CCPS) - Difficulty staying asleep scale | Scale of difficulty staying asleep, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSDiffStaySleepScl | Recommended | UDE |
| 24 | Concussion Clinical Profiles Screening (CCPS) - Trouble remembering things scale | Scale of trouble remembering things, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSTrblRmbrThngsScl | Recommended | UDE |
| 25 | Concussion Clinical Profiles Screening (CCPS) - Difficulty moving neck scale | Scale of difficulty moving neck, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSDiffMvNeckScl | Recommended | UDE |
| 26 | Concussion Clinical Profiles Screening (CCPS) - Feeling nervous or anxious scale | Scale of feeling nervous or anxious scale, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSFeelngNervAnxScl | Recommended | UDE |
| 27 | Concussion Clinical Profiles Screening (CCPS) - Increased headache after physical activity scale | Scale of increased headache after physical activity, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSIncHeadachPhysActScl | Recommended | UDE |
| 28 | Concussion Clinical Profiles Screening (CCPS) - Increased headache after cognitive activity scale | Scale of increased headache after cognitive activity, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSIncHeadachCogActScl | Recommended | UDE |
| 29 | Concussion Clinical Profiles Screening (CCPS) - Feeling more stressed scale | Scale of feeling more stressed, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSFeelngMoreStressedScl | Recommended | UDE |
SCORING SHEET (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Concussion Clinical Profiles Screening (CCPS) - Anxiety/mood raw score | Score (raw) anxiety/mood, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSAnxMoodRawScore | Recommended | UDE |
| 2 | Concussion Clinical Profiles Screening (CCPS) - Anxiety/mood average score | Score (average) anxiety/mood, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSAnxMoodAvgScore | Recommended | UDE |
| 3 | Concussion Clinical Profiles Screening (CCPS) - Cognitive/fatigue raw score | Score (raw) cognitive/fatigue, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSCogFatigRawScore | Recommended | UDE |
| 4 | Concussion Clinical Profiles Screening (CCPS) - Cognitive/fatigue average score | Score (average) cognitive/fatigue, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSCogFatigAvgScore | Recommended | UDE |
| 5 | Concussion Clinical Profiles Screening (CCPS) - Migraine raw score | Score (raw) migraine, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSMigraineRawScore | Recommended | UDE |
| 6 | Concussion Clinical Profiles Screening (CCPS) - Migraine average score | Score (average) migraine, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSMigraineAvgScore | Recommended | UDE |
| 7 | Concussion Clinical Profiles Screening (CCPS) - Ocular raw score | Score (raw) ocular, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSOcularRawScore | Recommended | UDE |
| 8 | Concussion Clinical Profiles Screening (CCPS) - Ocular average score | Score (average) ocular, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSOcularAvgScore | Recommended | UDE |
| 9 | Concussion Clinical Profiles Screening (CCPS) - Vestibular raw score | Score (raw) vestibular, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSVestibularRawScore | Recommended | UDE |
| 10 | Concussion Clinical Profiles Screening (CCPS) - Vestibular average score | Score (average) vestibular, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSVestibularAvgScore | Recommended | UDE |
| 11 | Concussion Clinical Profiles Screening (CCPS) - Sleep raw score | Score (raw) sleep, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSSleepRawScore | Recommended | UDE |
| 12 | Concussion Clinical Profiles Screening (CCPS) - Sleep average score | Score (average) sleep, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSSleepAvgScore | Recommended | UDE |
| 13 | Concussion Clinical Profiles Screening (CCPS) - Neck raw score | Score (raw) neck, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSNeckRawScore | Recommended | UDE |
| 14 | Concussion Clinical Profiles Screening (CCPS) - Neck average score | Score (average) neck, as part of Concussion Clinical Profiles Screening (CCPS) | CCPSNeckAvgScore | Recommended | UDE |
| 15 | Concussion Clinical Profiles Screening (CCPS) - Total raw score | Score total (raw), as part of Concussion Clinical Profiles Screening (CCPS) | CCPSTotalRawScore | Recommended | UDE |
Keywords
