Form Structure: NIH Toolbox Emotion Domain Peer Rejection Survey Parent Report Ages 3-12
This form structure is an organized set of data definitions for a copyrighted form
Title:
NIH Toolbox Emotion Domain Peer Rejection Survey Parent Report Ages 3-12
Short Name:
NIHTBPeerRejectionPR3to12
Description:
As an analogue to the NIH Toolbox Perceived Rejection Survey, the NIH Toolbox Peer Rejection Survey is a parent-report measure for children ages 3-12. It is a 9-item fixed-length form that assesses how often a child is left out, avoided, or teased by peers. 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:
2016-07-11
Owner:
Number of Data Elements:
40
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 administration language type | Type of language for test being administrated, as part of the NIH Toolbox | NIHTBTestAdminLanguageTyp | Recommended | CDE |
| 4 | NIH Toolbox - Test administration language type other | Free-text related to NIHTBTestAdminLanguageTyp specifying other text, as part of the NIH Toolbox | NIHTBTestAdminLanguageTypOTH | Recommended | CDE |
| 5 | NIH Toolbox - Test name type | Type of NIH Toolbox test being administered, as part of the NIH Toolbox | NIHTBAdminTestNameTyp | Recommended | CDE |
| 6 | NIH Toolbox - Test name type other | The free-text related to NIHTBAdminTestNameTyp specifying other text, as part of the NIH Toolbox | NIHTBAdminTestNameTypOTH | 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 Peer Rejection Survey PR Ages 3-12 (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Left out scale | Scale for the parent reported statement: How often your child is left out by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12LeftOutScl | Recommended | CDE |
| 2 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Refuse play scale | Scale for the parent reported statement How often other children refuse to let your child play with them, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12RefusePlyScl | Recommended | CDE |
| 3 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Playmate scale | Scale for the parent reported statement How often your child is not chosen as a playmate, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12PlaymateScl | Recommended | CDE |
| 4 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Rejected scale | Scale for the parent reported statement How often your child is actively rejected by other children who refuse to play with him/her, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12RejectedScl | Recommended | CDE |
| 5 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Avoided scale | Scale for the parent reported statement How often your child is avoided by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12AvoidedScl | Recommended | CDE |
| 6 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Liked scale | Scale for the parent reported statement How often your child is not well liked by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12LikedScl | Recommended | CDE |
| 7 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Picked on scale | Scale for the parent reported statement How often your child is picked on, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12PickedOnScl | Recommended | CDE |
| 8 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Teased scale | Scale for the parent reported statement How often your child is teased and made fun of by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12TeasedScl | Recommended | CDE |
| 9 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Pushed scale | Scale for the parent reported statement How often your child is pushed or shoved around by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12PushedScl | Recommended | CDE |
NIH Toolbox Peer Rejection Survey Prt Rpt 3-12 Scoring (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Raw score | Raw score, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12RawScore | Recommended | CDE |
| 2 | NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Theta score | Theta score, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. | NIHTBPRPRFF3to12ThetaScore | 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 |
Keywords
