Form Structure: Galveston Orientation and Amnesia Test (GOAT)
This form structure is an organized set of data definitions for a copyrighted form
Title:
Galveston Orientation and Amnesia Test (GOAT)
Short Name:
GOAT_FITBIR
Description:
The GOAT can be administered to assess the duration of post-traumatic amnesia, including ten items on recovery of orientation to person, place, and time. The duration of retrograde and anterograde amnesia can be assessed. It is appropriate for ages 16 and older. Recommended by CDISC for TBI (TAUG TBI)
Disease:
Traumatic Brain Injury
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-04-19
Version:
1.2
Date Created:
2015-03-12
Owner:
Number of Data Elements:
30
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 | 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 |
Additional Element Groups
Listed below are your additional element groups.
Form Administration Group (Repeat Infinitely)
| # | 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 |
Galveston Orientation & Amnesia Test (GOAT) (Repeat Infinitely)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | The Galveston Orientation and Amnesia Test (GOAT) - Full name score | Scored ability to accurately state first and last name, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATNameScore | Recommended | CDE |
| 2 | The Galveston Orientation and Amnesia Test (GOAT) - Born date score | Scored ability to accurately state date of birth, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATBrnDateScore | Recommended | CDE |
| 3 | The Galveston Orientation and Amnesia Test (GOAT) - Live location score | Scored ability to accurately state place of residence, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATLiveLocScore | Recommended | CDE |
| 4 | The Galveston Orientation and Amnesia Test (GOAT) - City location score | Scored ability to accurately name the city the subject is currently located, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATCityLocScore | Recommended | CDE |
| 5 | The Galveston Orientation and Amnesia Test (GOAT) - Building location score | Scored ability to accurately identify the building they are currently located, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATBuildingLocScore | Recommended | CDE |
| 6 | The Galveston Orientation and Amnesia Test (GOAT) - Hospital admittance date score | Scored ability to accurately identify hospital admittance date, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATHospAdmtDateScore | Recommended | CDE |
| 7 | The Galveston Orientation and Amnesia Test (GOAT) - Mode of transportation score | Scored ability to accurately identify the mode of transportation to the hospital, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATModeTranspScore | Recommended | CDE |
| 8 | The Galveston Orientation and Amnesia Test (GOAT) - Post injury event score | Scored ability to provide specific details about the first event after injury, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATFirstEvntScore | Recommended | CDE |
| 9 | The Galveston Orientation and Amnesia Test (GOAT) - Post injury event detail score | Scored ability to identify the detail of the first event the subject can remember after the accident, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATDetailScore | Recommended | CDE |
| 10 | The Galveston Orientation and Amnesia Test (GOAT) - Pre injury event score | Scored ability to accurately recall the last event before injury, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATLastEvntScore | Recommended | CDE |
| 11 | The Galveston Orientation and Amnesia Test (GOAT) - Pre injury event detail score | Scored ability to provide specific details about the last event before injury, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATPreInjuEventDetailScore | Recommended | CDE |
| 12 | The Galveston Orientation and Amnesia Test (GOAT) - Time score | Scored ability to identify the current time, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATCrntTimeScore | Recommended | CDE |
| 13 | The Galveston Orientation and Amnesia Test (GOAT) - Day week score | Scored ability to identify the current day of the week, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATDayScore | Recommended | CDE |
| 14 | The Galveston Orientation and Amnesia Test (GOAT) - Day month score | Scored ability to identify the current day of the month, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATDayMnthDateScore | Recommended | CDE |
| 15 | The Galveston Orientation and Amnesia Test (GOAT) - Month score | Scored ability to identify the current month, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATMnthScore | Recommended | CDE |
| 16 | The Galveston Orientation and Amnesia Test (GOAT) - Year identification score | Scored ability to identify the current year, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATYearScore | Recommended | CDE |
| 17 | The Galveston Orientation and Amnesia Test (GOAT) - Error sum value | Galveston Orientation and Amnesia Test (GOAT) sum of errors value | GOATErrorSumVal | Recommended | CDE |
| 18 | The Galveston Orientation and Amnesia Test (GOAT) - Total score | Total score, as part of the Galveston Orientation and Amnesia Test (GOAT). | GOATTotalScore | Recommended | CDE |
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