Form Structure: Death Report
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
Death Report
Short Name:
Death_Report
Description:
The Death Report CRF Module should only be completed in the event of the participant's/subject's death while enrolled in the study. It captures the date, time and the medical reason death is attributed.Based on NINDS F0388_Deat from.
Disease:
General (For all diseases)
Traumatic Brain Injury
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2023-11-21
Version:
1.0
Date Created:
2014-04-09
Owner:
Number of Data Elements:
25
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 | Recommended | 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 |
Death report (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Death date and time | Date (and time, if known) of participant's/subject's death | DeathDateTime | Optional | CDE |
| 2 | Injury elapsed time | The elapsed time (in minutes) from the time of injury | InjElapsedTime | Recommended | CDE |
| 3 | Death cause ICD-10-CM code | ICD-10-CM code that describes the cause of participant/subject's death | DeathCauseICD10CMCode | Recommended | CDE |
| 4 | Death cause text | Text describing the primary reason or cause of the participant/subject's death. If possible, this should be the explanation of the cessation of life according to the Death Certificate. | DeathCauseTxt | Optional | CDE |
| 5 | Death location type | Type of location where the participant/subject died | DeathLoctnTyp | Recommended | CDE |
| 6 | Death location other text | The free-text field related to 'Death location type' specifying other text. Type of location where the participant/subject died | DeathLoctnOTH | Recommended | CDE |
| 7 | Diagnosis final clinical death date | Date of participant's/subject's final clinical diagnosis | DiagnosFinalClinDeathDate | Optional | CDE |
| 8 | Diagnosis final clinical death type | Physician's final clinical diagnosis for the participant/subject | DiagnosFinalClinDeathTyp | Recommended | CDE |
| 9 | Diagnosis final clinical death other text | The free-text field related to 'Diagnosis final clinical death type' specifying other text. Physician's final clinical diagnosis for the participant/subject | DiagnosFinalClinDeathOTH | Recommended | CDE |
| 10 | Clinical event or milestone type | Type of clinical event or milestone pertinent to the disease or disorder | ClinEvntMilestoneTyp | Optional | CDE |
Keywords
