Form Structure: NIH Toolbox Sensation Domain Hearing Handicap Inventory (Supplementary Measure)
This form structure is an organized set of data definitions for a copyrighted form
Title:
NIH Toolbox Sensation Domain Hearing Handicap Inventory (Supplementary Measure)
Short Name:
NIHTBHearingHandicpInvntry
Description:
This supplemental instrument is a brief, reliable self-report measure of hearing-related disability. There is a 10-item survey for adults ages 18-64, and another 10-item form for ages 65-85. This survey has validity in studies that examine correlations with audiometric testing (e.g., pure tone audiometry, such as the NIH Toolbox Hearing Threshold Test). This test can be administered to participants ages 18 and older and requires three minutes to administer. 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:
2016-06-20
Owner:
Number of Data Elements:
48
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 HHIE-Screening (HHIE-S) (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Hearing Handicap Inventory (HHI) - Embarrassed to meet new people scale | Scale of when a hearing problem causes the subject to feel embarrassed when meeting new people, as part of the Hearing Handicap Inventory (HHI) | HHIEmbarrasMeetNewPplScl | Recommended | CDE |
| 2 | Hearing Handicap Inventory (HHI) - Frustrated talking to family scale | Scale of when a hearing problem causes the subject to feel frustrated when talking to members of the family, as part of the Hearing Handicap Inventory (HHI) | HHIFrustratTalkFamilyScl | Recommended | CDE |
| 3 | Hearing Handicap Inventory(HHI) - Difficulty hearing when someone whispers scale | Scale of when the subject has difficulty hearing when someone speaks in a whisper, as part of the Hearing Handicap Inventory(HHI) | HHIDiffHearWhisperScl | Recommended | CDE |
| 4 | Hearing Handicap Inventory (HHI) - Felt handicapped by hearing problem scale | Scale of when the subject feels handicapped by a hearing problem, as part of the Hearing Handicap Inventory (HHI) | HHIFeltHandcapHearProbScl | Recommended | CDE |
| 5 | Hearing Handicap Inventory (HHI) - Difficulty hearing when visiting friends scale | Scale of when a hearing problem causes the subject difficulty when visiting friends, relatives, or neighbors, as part of the Hearing Handicap Inventory (HHI) | HHIDiffHearVisitFriendScl | Recommended | CDE |
| 6 | Hearing Handicap Inventory (HHI) - Limits religious attendance scale | Scale of when a hearing problem causes the subject to attend religious services less often than they would like, as part of the Hearing Handicap Inventory (HHI) | HHILimitReligiousAttndScl | Recommended | CDE |
| 7 | Hearing Handicap Inventory (HHI) - Causes arguments with family scale | Scale of when a hearing problem causes the subject to have arguments with family members, as part of the Hearing Handicap Inventory (HHI) | HHICauseArgumntFamilyScl | Recommended | CDE |
| 8 | Hearing Handicap Inventory (HHI) - Difficulty listening to TV scale | Scale of when a hearing problem causes the subject difficulty when listening to TV or radio, as part of the Hearing Handicap Inventory (HHI) | HHIDiffListenTVScl | Recommended | CDE |
| 9 | Hearing Handicap Inventory (HHI) - Limits social life scale | Scale of when the subject feels that any difficulty with their hearing limits or hampers their personal or social life, as a part of the Hearing Handicap Inventory (HHI) | HHILimitSocialLifeScl | Recommended | CDE |
| 10 | Hearing Handicap Inventory (HHI) - Difficulty hearing in restaurants scale | Scale of when a hearing problem causes the subject difficulty when in a restaurant with relatives or friends, as part of the Hearing Handicap Inventory (HHI) | HHIDiffHearRestaurantScl | Recommended | CDE |
| 11 | Hearing Handicap Inventory (HHI) - 10 Item sum score | Sum score, as part of the 10-item Hearing Handicap Inventory (HHI) screening test | HHIScreening10ItemSumScore | Recommended | CDE |
| 12 | 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 |
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 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 HHIA-Screening (HHIA-S) (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Hearing Handicap Inventory (HHI) - Embarrassed to meet new people scale | Scale of when a hearing problem causes the subject to feel embarrassed when meeting new people, as part of the Hearing Handicap Inventory (HHI) | HHIEmbarrasMeetNewPplScl | Recommended | CDE |
| 2 | Hearing Handicap Inventory (HHI) - Frustrated talking to family scale | Scale of when a hearing problem causes the subject to feel frustrated when talking to members of the family, as part of the Hearing Handicap Inventory (HHI) | HHIFrustratTalkFamilyScl | Recommended | CDE |
| 3 | Hearing Handicap Inventory for Adults (HHIA) - Difficulty hearing at work scale | Scale of when a hearing problem causes the subject difficulty hearing/understanding coworkers, clients, or customers, as part of the Hearing Handicap Inventory (HHI) | HHIADiffHearWorkScl | Recommended | CDE |
| 4 | Hearing Handicap Inventory (HHI) - Felt handicapped by hearing problem scale | Scale of when the subject feels handicapped by a hearing problem, as part of the Hearing Handicap Inventory (HHI) | HHIFeltHandcapHearProbScl | Recommended | CDE |
| 5 | Hearing Handicap Inventory (HHI) - Difficulty hearing when visiting friends scale | Scale of when a hearing problem causes the subject difficulty when visiting friends, relatives, or neighbors, as part of the Hearing Handicap Inventory (HHI) | HHIDiffHearVisitFriendScl | Recommended | CDE |
| 6 | Hearing Handicap Inventory for Adults (HHIA) - Difficulty hearing in movie theater scale | Scale of when a hearing problem causes the subject difficulty in movies or theater, as part of the Hearing Handicap Inventory for Adults (HHIA) | HHIADiffHearMovieTheatrScl | Recommended | CDE |
| 7 | Hearing Handicap Inventory (HHI) - Causes arguments with family scale | Scale of when a hearing problem causes the subject to have arguments with family members, as part of the Hearing Handicap Inventory (HHI) | HHICauseArgumntFamilyScl | Recommended | CDE |
| 8 | Hearing Handicap Inventory (HHI) - Difficulty listening to TV scale | Scale of when a hearing problem causes the subject difficulty when listening to TV or radio, as part of the Hearing Handicap Inventory (HHI) | HHIDiffListenTVScl | Recommended | CDE |
| 9 | Hearing Handicap Inventory (HHI) - Limits social life scale | Scale of when the subject feels that any difficulty with their hearing limits or hampers their personal or social life, as a part of the Hearing Handicap Inventory (HHI) | HHILimitSocialLifeScl | Recommended | CDE |
| 10 | Hearing Handicap Inventory (HHI) - Difficulty hearing in restaurants scale | Scale of when a hearing problem causes the subject difficulty when in a restaurant with relatives or friends, as part of the Hearing Handicap Inventory (HHI) | HHIDiffHearRestaurantScl | Recommended | CDE |
| 11 | Hearing Handicap Inventory (HHI) - 10 Item sum score | Sum score, as part of the 10-item Hearing Handicap Inventory (HHI) screening test | HHIScreening10ItemSumScore | Recommended | CDE |
| 12 | 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 |
Keywords
