Form Structure: FITBIR Demographics Form
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
FITBIR Demographics Form
Short Name:
DemogrFITBIR
Description:
FITBIR Demographics standard form
Disease:
Traumatic Brain Injury
Required Program Form:
Yes
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-04-17
Version:
1.1
Date Created:
2015-01-22
Owner:
Number of Data Elements:
137
eForms:
Y
Logically grouped data elements with defined frequency at which they repeat.
There are no data elements in the main group.
Additional Element Groups
Listed below are your additional element groups.
Main Group (Appears Exactly 1 Time)
| # | 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 | Required | CDE |
| 4 | Visit date | Actual interview or visit date | VisitDate | Recommended | CDE |
| 5 | Site name | The name of the site for the study | SiteName | Recommended | CDE |
| 6 | Days since baseline | The number of days since baseline | DaysSinceBaseline | Optional | CDE |
| 7 | Case control indicator | Indicator of whether subject is in the case or control arm of the study. | CaseContrlInd | Optional | CDE |
| 8 | General notes text | General notes | GeneralNotesTxt | Optional | CDE |
Form Administration (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Context type | The context to which the questions were answered | ContextType | Recommended | CDE |
| 2 | Context type other text | The free-text related to ContextType specifying other text | ContextTypeOTH | Recommended | CDE |
| 3 | Data source | Source of the data provided on the case report form | DataSource | Recommended | CDE |
| 4 | 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 |
Subject Demographics (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Birth date | Date (and time, if applicable and known) the participant/subject was born | BirthDate | Optional | CDE |
| 2 | Gender Type | Self-reported gender of the participant/subject. Gender is the socially constructed identity of sex. | GenderTyp | Recommended | CDE |
| 3 | Sex participant or subject genotype type | Sex chromosomes of the participant/subject based upon genotyping | SexSubjectGenotypTyp | Recommended | CDE |
| 4 | Sex participant or subject genotype other text | The free-text field related to Sex participant or subject genotype type specifying other text. Sex chromosomes of the participant/subject based upon genotyping | SexSubjectGenotypOTH | Recommended | CDE |
| 5 | Hand preference type | Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusively. | HandPrefTyp | Recommended | CDE |
| 6 | Race USA category | The subject self declared racial origination, independent of ethnic origination, using OMB approved categories. | RaceUSACat | Recommended | CDE |
| 7 | Race category | Category of race(s) or region(s) the participant/subject most closely identifies with | RaceCat | Recommended | CDE |
| 8 | Ethnicity USA category | Category of ethnicity the participant/subject most closely identifies with | EthnUSACat | Recommended | CDE |
| 9 | Ethnicity category | The free-text field describing the category of ethnicity the participant/subject most closely identifies with. | EthnCatTxt | Recommended | CDE |
Subject Country of Birth and Current Residency (Appears Up To 5 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Birth country ISO code | Code (ISO 3166-1 alpha-2 code) for country where the participant/subject was born | BirthCntryISOCode | Recommended | CDE |
| 2 | Birth country name | Name for country where the participant/subject was born | BirthCntryName | Recommended | CDE |
| 3 | Country of residence ISO code | Code (ISO 3166-1 alpha-2) for the country where the participant/subject currently lives. | CntryResdnceISOCode | Recommended | CDE |
| 4 | Country of residence name | Name of the country where the participant/subject currently lives. | CntryResdnceName | Recommended | CDE |
Subject Language (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Language primary ISO code | Code (ISO 639-2 alpha-3 code) for the language the participant/subject speaks most often. | LangPrimryTxt | Recommended | CDE |
| 2 | Language primary other text | The free-text field related to Language primary text specifying other text. Text for the language the participant/subject speaks most often | LangPrimryOTH | Recommended | CDE |
| 3 | Language spoken fluent code | Code (ISO 639-2)for each language that the participant/subject speaks fluently | LangSpokeFluentISOCode | Recommended | CDE |
| 4 | Language spoken Fluent text | Text for each language that the participant/subject speaks fluently | LangSpokeFluentTxt | Recommended | CDE |
| 5 | Language written fluent ISO code | Code (ISO 639-2) for each language that the participant/subject writes fluently | LandWrtnFlntlyISOCode | Recommended | CDE |
| 6 | Language written fluent text | Text for each language that the participant/subject writes fluently | LangWrtnFlntlyTxt | Recommended | CDE |
Subject Marital Status (Appears Up To 5 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Marital or partner status | Status of participant/subjects current domestic relationship, whether marital or partnered | MartlPartnerStatus | Recommended | CDE |
| 2 | Marital or partner status other text | The free-text field related to Marital or partner status specifying other text. Status of participant/subjects current domestic relationships. | MartlPartnerStatusOTH | Recommended | CDE |
Subject Living Situation (Appears Up To 5 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Living situation of an adult subject | Living situation of an adult subject, including the primary person living with adult subject information | SesPrimAdult | Recommended | CDE |
| 2 | Other primary person living with adult patient | Other Primary person living with adult patient | SesPrimAdultOther | Recommended | CDE |
| 3 | Living situation of juvenile patient | Living situation of juvenile patient | SesPrimChild | Recommended | CDE |
| 4 | Living situation of juvenile patient other text | Living situation of juvenile patient other text | SesPrimChildOTH | Recommended | CDE |
| 5 | Living situation before injury type | Living situation of the participant/subject before injury. | LivingSituationPreInjTyp | Recommended | CDE |
| 6 | Living situation before injury type, specifying other text | The free-text related to "LivingSituationPreInjTyp" specifying other text. | LivingSituationPreInjTypOTH | Recommended | CDE |
| 7 | Subject cohabitants count | Count of other people with whom the participant/subject currently lives, cohabits, or stays | SubjectCohabitCt | Recommended | CDE |
| 8 | Dependent children living in household number | Number of dependent children living in household | DpndntChildLvngHshldNum | Recommended | CDE |
| 9 | Number of dependent children | Number of dependent children for a participant/subject | DependentChildNum | Recommended | CDE |
| 10 | Residence area type | Type describing the participant's/subjects current location of residence | ResidenceAreaTyp | Recommended | CDE |
| 11 | Residence type | Type of residence where the participant/subject is currently living | ResdncTyp | Recommended | CDE |
| 12 | Residence other text | The free-text field related to Residence type specifying other text. Type of residence where the participant/subject is currently living | ResdncOTH | Recommended | CDE |
Subject Family Income (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Family income range | Range, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FmlyIncRange | Recommended | CDE |
| 2 | Family income supported persons count | Count of all people, including the participant/subject, who are supported by the household gross annual income reported | FamilyIncmeSupprtPersCt | Recommended | CDE |
| 3 | Family income value | Value, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FamilyIncmeVal | Recommended | CDE |
| 4 | Household wage earners number | Number of wage earners in household | HshldWgeEarnNum | Recommended | CDE |
| 5 | Income basic needs status | The status of how the household currently manages to meet basic needs as defined by food, shelter and clothing. | IncomeBasicNeedsStatus | Recommended | CDE |
Subject Education (Appears Up To 3 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Education level USA type | Highest grade or level of school participant/subject has completed or the highest degree received | EduLvlUSATyp | Recommended | CDE |
| 2 | Education level USA type other text | The free-text field related to Education level USA type, specifying other text. The highest level of education the participant/subject received. | EduLvlUSATypOTH | Recommended | CDE |
| 3 | Education type | The type of education the participant/subject received. | EduTyp | Recommended | CDE |
| 4 | Education other text | The free-text field related to Education type specifying other text. The type of education the participant/subject received. | EduOTH | Recommended | CDE |
| 5 | Education year count | Number of years of education completed (age 5 and beyond) | EduYrCt | Recommended | CDE |
| 6 | Highest level education pre-injury | Highest level education pre-injury | HighestLvlEduPreInj | Recommended | CDE |
| 7 | Education school participation status | Status of participant/subjects current attendance at school | EduSchoolParticipStatus | Recommended | CDE |
| 8 | School placement type | The description of the type of education the participant/subject receives with details of being with or without assistance. | SchoolPlacementTyp | Recommended | CDE |
| 9 | School placement other text | The free-text field related to School placement type specifying other text. The description of the type of education the participant/subject receives with details of being with or without assistance. | SchoolPlacementOTH | Recommended | CDE |
Subject Occupation and Employment (Appears Up To 10 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Occupation primary status | The status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatus | Recommended | CDE |
| 2 | Occupation primary status other text | The free-text field to capture other status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatusOTH | Recommended | CDE |
| 3 | Employment expanded status | Status of participant/subjects current employment | EmplmtExpndStatus | Recommended | CDE |
| 4 | Employment expanded other text | The free-text field related to Employment expanded status specifying other text. Status of participant/subjects current employment | EmplmtExpndOTH | Recommended | CDE |
| 5 | Job classification pre-injury | Job classification pre-injury | JobClassPreInj | Recommended | CDE |
| 6 | Job classification pre-injury other text | The free-text field related to Job classification pre-injury specifying other text. | JobClassPreInjOTH | Recommended | CDE |
| 7 | Job classification-now | Job classification-now | JobClassNow | Recommended | CDE |
| 8 | Job classification-now other text | The free-text field related to Job classification-now specifying other text. | JobClassNowOTH | Recommended | CDE |
| 9 | Unemployed reason | Participant/subject reason for unemployment | UnemplymntRsn | Recommended | CDE |
Parent Guardian or Caregiver Information (Appears Up To 6 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Primary caregiver extended type | Type of relationship between the person who acts as the primary caregiver for the participant/subject and the participant/subject | CaregvPrimryExtendType | Recommended | CDE |
| 2 | Primary caregiver extended type other text | The free-text field related to Primary caregiver extended type. | CaregvPrimryExtendOTH | Recommended | CDE |
| 3 | Alive status of subjects parents | Specifies whether the participant's/subjects parents are still living | ParentAliveStatus | Recommended | CDE |
| 4 | Gender Type | Self-reported gender of the participant/subject. Gender is the socially constructed identity of sex. | GenderTyp | Recommended | CDE |
| 5 | Race USA category | The subject self declared racial origination, independent of ethnic origination, using OMB approved categories. | RaceUSACat | Recommended | CDE |
| 6 | Race category | Category of race(s) or region(s) the participant/subject most closely identifies with | RaceCat | Recommended | CDE |
| 7 | Ethnicity USA category | Category of ethnicity the participant/subject most closely identifies with | EthnUSACat | Recommended | CDE |
| 8 | Ethnicity category | The free-text field describing the category of ethnicity the participant/subject most closely identifies with. | EthnCatTxt | Recommended | CDE |
| 9 | Birth country ISO code | Code (ISO 3166-1 alpha-2 code) for country where the participant/subject was born | BirthCntryISOCode | Recommended | CDE |
| 10 | Birth country name | Name for country where the participant/subject was born | BirthCntryName | Recommended | CDE |
| 11 | Marital or partner status | Status of participant/subjects current domestic relationship, whether marital or partnered | MartlPartnerStatus | Recommended | CDE |
| 12 | Dependent children living in household number | Number of dependent children living in household | DpndntChildLvngHshldNum | Recommended | CDE |
| 13 | Number of dependent children | Number of dependent children for a participant/subject | DependentChildNum | Recommended | CDE |
| 14 | Residence area type | Type describing the participant's/subjects current location of residence | ResidenceAreaTyp | Recommended | CDE |
| 15 | Residence type | Type of residence where the participant/subject is currently living | ResdncTyp | Recommended | CDE |
| 16 | Residence other text | The free-text field related to Residence type specifying other text. Type of residence where the participant/subject is currently living | ResdncOTH | Recommended | CDE |
| 17 | Education level primary caregiver USA type | Highest grade or level of school the participant's/subjects primary caregiver has completed or the highest degree he/she has received | EduLvlPrimCaregiverUSATyp | Recommended | CDE |
| 18 | Education primary caregiver year count | Number of years of education of the primary caregiver (age 5 and beyond). | EduPrimCaregiverYrCt | Recommended | CDE |
| 19 | Occupation primary status | The status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatus | Recommended | CDE |
| 20 | Occupation primary status other text | The free-text field to capture other status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatusOTH | Recommended | CDE |
| 21 | Job classification category | Category that classifies work performed by participant/subject. | JobclassCat | Recommended | CDE |
| 22 | Employment expanded status | Status of participant/subjects current employment | EmplmtExpndStatus | Recommended | CDE |
| 23 | Employment expanded other text | The free-text field related to Employment expanded status specifying other text. Status of participant/subjects current employment | EmplmtExpndOTH | Recommended | CDE |
| 24 | Unemployed reason | Participant/subject reason for unemployment | UnemplymntRsn | Recommended | CDE |
| 25 | Family income range | Range, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FmlyIncRange | Recommended | CDE |
| 26 | Family income value | Value, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FamilyIncmeVal | Recommended | CDE |
| 27 | Family income supported persons count | Count of all people, including the participant/subject, who are supported by the household gross annual income reported | FamilyIncmeSupprtPersCt | Recommended | CDE |
Subject Military Status (Appears Up To 3 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Active military status indicator | Whether participant currently has active military status | MilActiveInd | Recommended | CDE |
| 2 | Military occupational status of participant | Military occupational status of participant | MilMOS | Optional | CDE |
| 3 | Military occupational status of participant other text | Military occupational status of participant other text | MilMOSOTH | Optional | CDE |
| 4 | Military USA service branch type | Branch of service in the U.S. military, not including the Commissioned Corps | MilUSAServBrnchTyp | Optional | CDE |
| 5 | Military USA service branch other text | The free-text field related to Military USA service branch type specifying other text. Branch of service in the U.S. military, not including the Commissioned Corps | MilUSAServBrnchOTH | Optional | CDE |
| 6 | Military rank category | Category that describes the participant's/subjects rank in the military | MilRnkCat | Optional | CDE |
| 7 | Military rank category other text | The free-text field related to Military rank category specifying other text. Category that describes the participant's/subjects rank in the military | MilRnkCatOTH | Optional | CDE |
| 8 | To where the military patient was deployed | Region or country the military patient was deployed | MilDeploy | Optional | CDE |
| 9 | To where the military patient was deployed other text | Region or country to where the military patient was deployed other text | MilDeployOTH | Optional | CDE |
Subject Involvement in Sports (Appears Up To 10 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Injury from sports indicator | TBI Screen: Injured head/neck doing sports | TBISportInd | Optional | CDE |
| 2 | Sport(s) participation in elementary school indicator | Whether subject participated in sport(s) in elementary school | ElementarySchoolSprtInd | Optional | CDE |
| 3 | Primary elementary school sport played | The primary sport the participant played in elementary school | ElementarySchoolPrimaryPlayed | Optional | CDE |
| 4 | Years played sports elementary school number | Number of years subject played sport(s) in elementary school | ElementarPrimarySprtYrsNum | Optional | CDE |
| 5 | Other sports subject played in elementary school | Which other sports the participant played in elementary school | ElementarySchoolSportOthrPlayd | Optional | CDE |
| 6 | Total combined years the participant played other elementary school sport(s) | Total combined number of years the participant played other sport(s) in elementary school | ElementarySchoolSportOtherYrs | Optional | CDE |
| 7 | Sport(s) participation in junior high school indicator | Whether subject played sports in junior high school | JuniorHighSchoolSportInd | Optional | CDE |
| 8 | Primary sport subject played in junior high school | Which sports subject played in junior high school | JuniorHighPrimarySportPlayed | Optional | CDE |
| 9 | Years played sports junior high school number | Number of years subject played sport(s) in junior high school | JuniorHighPrimarySprtYrsNum | Optional | CDE |
| 10 | Other sports subject played in Junior high school | Which sports subject played inJunior high school | JuniorHighSportOtherplayed | Optional | CDE |
| 11 | Total combined years the participant played other junior high school sport(s) | Total combined number of years subject played sport(s) junior high school | JuniorHighSportOtherYrs | Optional | CDE |
| 12 | Sport(s) participation in high school indicator | Whether subject played sports in high school | HighSchoolSportInd | Optional | CDE |
| 13 | Primary high school sport played | The primary sport the participant played in high school | HighSchoolSportPrimaryplayed | Optional | CDE |
| 14 | Years played primary high school sport number | Number of years subject played sport(s) in high school | HighSchoolPrimarySportYears | Optional | CDE |
| 15 | Other sports subject played in high school | Which sports subject played in high school | HighSchoolSportOtherplayed | Optional | CDE |
| 16 | Total combined years the participant played other high school sport(s) | Total combined number of years participant played other sport(s) in high school | HighSchoolSportOtherYears | Optional | CDE |
| 17 | Sport(s) participation in college indicator | Indicator whether the participant played sports in college. | CollegeSportInd | Optional | CDE |
| 18 | Primary college sport played by the participant | The primary sport the participant played in college. | CollegeSportPrimaryPlayed | Optional | CDE |
| 19 | Total combined years the partisipant played primary college sport | Total combined years the partisipant played primary college sport. | CollegeSportPrimaryYears | Optional | CDE |
| 20 | Other sport(s) the participant played in college | Other sports the participant played in college. A complimentary UDE for "Primary college sport played by the participant". | CollegeSportPlayedOTH | Optional | CDE |
| 21 | College sport other played | College sports played other than primary sport | CollegeSportOtherPlayed | Optional | CDE |
| 22 | Total combined years the partisipant played other college sport(s) | Total combined years the partisipant played other college sport(s). | CollegeSportOtherYears | Optional | CDE |
| 23 | Recreational sport(s) participation indicator | Whether the participant played recreational sports | RecreationallSportInd | Optional | CDE |
| 24 | Primary recreational sport played by the participant | Which sport the participant primarily played recreationally | RecreationaSportPrimaryPlayed | Optional | CDE |
| 25 | Total combined years the participant played primary recreational sport | Total number of years the participant played primary sport recreationally | RecreationaSportPrimaryYears | Optional | CDE |
| 26 | Other recreational sports played by the participant | Which other sport(s) the participant played recreationally | RecreationaSportOtherPlayed | Optional | CDE |
| 27 | Total combined years the participant played other recreational sport(s) | Total number of years subject played other sport(s) recreationally | RecreationaSportOtherYears | Optional | CDE |
| 28 | Professional sport(s) participation indicator | Indicator whether the participant played sports professionally. | ProfessionalSportInd | Optional | CDE |
| 29 | Primary professional sport played by the participant | The primary sport the participant played in college. | ProfessionalSportPrimaryPlayed | Optional | CDE |
| 30 | Total combined years the partisipant played primary professional sport | Total combined years the participant played primary professional sport (should be used in combination with Primary professional sport played by the participant UDE). | ProfessionalSportPrimaryYears | Optional | CDE |
| 31 | Other professional sports played by the participant | Other sports the participant played professionally. A complimentary UDE for Primary professional sport played by the participant. | ProfessionalSportPlayedOTH | Optional | CDE |
| 32 | Professional sport other played | Professional sports played othre than primary sport | ProfessionalSportOtherPlayed | Optional | CDE |
| 33 | Total combined years the partisipant played other professional sport(s) | Total combined years the participant played other professional sport(s) (should be used in combination with Other professional sports played by the participant. | ProfessionalSportOtherYears | Optional | CDE |
Keywords
