Form Structure: NIH Toolbox Emotion Domain Emotional Support Survey 18-85
This form structure is an organized set of data definitions for a copyrighted form
Title:
NIH Toolbox Emotion Domain Emotional Support Survey 18-85
Short Name:
NIHTBEmotionSupport18to85
Description:
The NIH Toolbox Emotional Support Survey is a self-report measure that assesses emotional support through two fixed-length forms: an 8-item form for ages 18-85 and a 7-item form for ages 8-17. There are no Parent-Report versions. iPad. Copyright 2012 Northwestern University and the National Institutes of Health. http://www.nihtoolbox.org/Pages/NIH-Toolbox-Terms-and-Conditions.aspx
Disease:
Traumatic Brain Injury
General (For all diseases)
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-07-14
Owner:
Number of Data Elements:
46
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 |
NIH Toolbox Administration (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox - Test domain battery type | Type of domain battery for the NIH Toolbox test being administered, as a part of the NIH Toolbox | NIHTBTestDomainBattryTyp | Recommended | CDE |
| 2 | NIH Toolbox - Test domain battery type other | The free-text related to NIHTBTestDomainBatteryTyp specifying other text, as part of the NIH Toolbox | NIHTBTestDomainBatteryTypOTH | Recommended | CDE |
| 3 | NIH Toolbox - Test name type | Type of NIH Toolbox test being administered, as part of the NIH Toolbox | NIHTBAdminTestNameTyp | Recommended | CDE |
| 4 | NIH Toolbox - Test name type other | The free-text related to NIHTBAdminTestNameTyp specifying other text, as part of the NIH Toolbox | NIHTBAdminTestNameTypOTH | Recommended | CDE |
| 5 | NIH Toolbox - Test administration language type | Type of language for test being administrated, as part of the NIH Toolbox | NIHTBTestAdminLanguageTyp | Recommended | CDE |
| 6 | NIH Toolbox - Test administration language type other | Free-text related to NIHTBTestAdminLanguageTyp specifying other text, as part of the NIH Toolbox | NIHTBTestAdminLanguageTypOTH | Recommended | CDE |
| 7 | NIH Toolbox - Form administered type | Type of NIH Toolbox form being administered, as part of the NIH Toolbox | NIHTBFormAdminTyp | Recommended | CDE |
| 8 | NIH Toolbox - Test administration flag indicator | Indicator of a flag for the NIH Toolbox test being administered, as part of the NIH Toolbox | NIHTBAdminTestFlagInd | Recommended | CDE |
| 9 | NIH Toolbox - Test administration flag type | Type of flag for the NIH Toolbox test being administered, as part of the NIH Toolbox | NIHTBAdminTestFlagTyp | Recommended | CDE |
NIH Toolbox Emotional Support Survey Ages 18-85 (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox Emotional Support - Understands scale | Scale of participant report of statement: I have someone who understands my problems, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSFUnderstandsScl | Recommended | CDE |
| 2 | NIH Toolbox Emotional Support - Listens scale | Scale of participant report of statement: I have someone who will listen to me when I need to talk, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSFListensScl | Recommended | CDE |
| 3 | NIH Toolbox Emotional Support 18+ - Talk scale | Scale of participant report of statement: I feel there are people I can talk to if I am upset, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSF18TalkScl | Recommended | CDE |
| 4 | NIH Toolbox Emotional Support - Bad day scale | Scale of participant report of statement: I have someone to talk with when I have a bad day, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSFBadDayScl | Recommended | CDE |
| 5 | NIH Toolbox Emotional Support 18+ - Problems scale | Scale of participant report of statement: I have someone I trust to talk with about my problems, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSF18ProblemsScl | Recommended | CDE |
| 6 | NIH Toolbox Emotional Support 18+ - Feelings scale | Scale of participant report of statement: I have someone I trust to talk with about my feelings, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSF18FeelingsScl | Recommended | CDE |
| 7 | NIH Toolbox Emotional Support - Advice scale | Scale of participant report of statement: I can get helpful advice from others when dealing with a problem, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSFAdviceScl | Recommended | CDE |
| 8 | NIH Toolbox Emotional Support 18+ - Suggestions scale | Scale of participant report of statement: I have someone to turn to for suggestions about how to deal with a problem, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSF18SuggestionsScl | Recommended | CDE |
NIH Toolbox Emotional Support 18-85 Scoring (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox Emotional Support 18+ - Raw score | Raw score, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSF18RawScore | Recommended | CDE |
| 2 | NIH Toolbox Emotional Support 18+ - Theta score | Theta score, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSF18ThetaScore | Recommended | CDE |
| 3 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Age-adjusted scale score | Age-adjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROAgeAdjSclScore | Recommended | CDE |
| 4 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Age-adjusted national percentile value | Value of age-adjusted national percentile, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROAgeAdjNationalPctVal | Recommended | CDE |
| 5 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Fully-adjusted scale score | Fully-adjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROFullyAdjSclScore | Recommended | CDE |
| 6 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Unadjusted scale score | Unadjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROUnadjSclScore | Recommended | CDE |
| 7 | NIH Toolbox - Standard error | Standard error (a statistical measure of variance that represents the margin of error for the Tscore), as part of the NIH Toolbox Web, Cat and iPad Cognition measures such as: Picture Vocabulary Test and Oral Reading Recognition Test. | NIHTBStandardError | Optional | CDE |
iPad Scoring (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox Emotional Support 18+ - Raw score | Raw score, during the past month, for participants ages 18+ as part of the NIH Toolbox Emotional Support Survey Short Form | NIHTBESSF18RawScore | Recommended | CDE |
| 2 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Unadjusted scale score | Unadjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROUnadjSclScore | Recommended | CDE |
| 3 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Age-adjusted scale score | Age-adjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROAgeAdjSclScore | Recommended | CDE |
| 4 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Fully-adjusted scale score | Fully-adjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROFullyAdjSclScore | Recommended | CDE |
| 5 |
NIH Toolbox Emotional Support Survey 18+ - Uncorrected T-Score (iPad)
(Draft) |
Uncorrected T-Score weighted and normally distributed against the U.S. Census, as part of the NIH Toolbox NIH Toolbox Emotional Support 18+ for iPad | NIHTBEmotSupp1885UncorTscore | Recommended | CDE |
| 6 | NIH Toolbox Patient Reported Outcome (PRO) Measures - Age-adjusted national percentile value | Value of age-adjusted national percentile, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures, including iPad app | NIHTBPROAgeAdjNationalPctVal | Recommended | CDE |
| 7 | NIH Toolbox - Standard error | Standard error (a statistical measure of variance that represents the margin of error for the Tscore), as part of the NIH Toolbox Web, Cat and iPad Cognition measures such as: Picture Vocabulary Test and Oral Reading Recognition Test. | NIHTBStandardError | Recommended | CDE |
Keywords
