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Form Structure: NIH Toolbox Emotion Domain Fear-Somatic Arousal Survey Ages 18-85

This form structure is an organized set of data definitions for a copyrighted form
Resource:
FITBIR
Title:
NIH Toolbox Emotion Domain Fear-Somatic Arousal Survey Ages 18-85
Short Name:
NIHTBFearSomaticAroslSurvy
Description:
This self-report measure assesses somatic symptoms related to arousal for ages 18-85, using a 6-item fixed-length form. No versions for other ages are available. Copyright 2012 Northwestern University and the National Institutes of Health. http://www.nihtoolbox.org/Pages/NIH-Toolbox-Terms-and-Conditions.aspx
Disease:
General (For all diseases) Traumatic Brain Injury
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-06-23
Owner:
Number of Data Elements:
36
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.

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Form Administration (Appears 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 Form Administration (Appears 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 type  Type of flag for the NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestFlagTyp Recommended CDE
9 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

NIH Toolbox Fear-Somatic Arousal Survey 18-85 (Appears 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Short of breath scale  Scale of participant report of statement:statement: I was short of breath, in the past 7 days, for ages 18+, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18ShrtBrthScl Recommended CDE
2 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Nauseous scale  Scale of participant report of statement:statement: I felt nauseous, in the past 7 days, for ages 18+, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18NauseousScl Recommended CDE
3 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Dizzy scale  Scale of participant report of statement:statement: I felt dizzy or lightheaded, in the past 7 days, for ages 18+, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18DizzyScl Recommended CDE
4 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Muscles scale  Scale of participant report of statement:statement: My muscles twitched or trembled, in the past 7 days, for ages 18+, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18MusclesScl Recommended CDE
5 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Heart scale  Scale of participant report of statement:statement: My heart was racing or pounding, in the past 7 days, for ages 18+, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18HeartScl Recommended CDE
6 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Sore scale  Scale of participant report of statement:statement: My muscles were tense or sore, in the past 7 days, for ages 18+, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18SoreScl Recommended CDE

NIH Toolbox Fear Somatic Arousal Survey 18-85 Scoring (Appears 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Raw score  Raw score, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18RawScore Recommended CDE
2 NIH Toolbox Emotion Domain Fear Somatic Arousal Short Form 18+ - Theta score  Theta score, as part of the NIH Toolbox Emotion Fear Somatic Arousal Short Form NIHTBFSASF18ThetaScore 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
Keywords