Form Structure: Neuro-QoL Emotional and Behavioral Dyscontrol Long Form : FITBIR : Federal Interagency Traumatic Brain Injury Research Informatics System

Form Structure: Neuro-QoL Emotional and Behavioral Dyscontrol Long Form

This form structure is an organized set of data definitions for a copyrighted form

Resource:

FITBIR

Title:

Neuro-QoL Emotional and Behavioral Dyscontrol Long Form

Short Name:

NeuroQoLEmotBehDyscrtlLF

Description:

Disease:

Traumatic Brain Injury General (For all diseases)

Organization:

FITBIR

Required Program Form:

Standardization:

Standard NINDS CDE

Labels:

Form Type:

Clinical Assessment

Version:

1.0

Date Created:

2016-12-28

Owner:

Number of Data Elements:

eForms:

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 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

NeuroQoL Form Administration (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Quality of Life in Neurological Disorders (Neuro-Qol) - Form administered status	The specific Neuro-Qol form administered status, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QoLFormStatus	Recommended	CDE

Emotional and Behavioral Dyscontrol (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Quality of Life - Temper control last week scale	The scale representing how often the participant had trouble controlling his or her temper in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLTempCntrlLastWkScl	Recommended	CDE
2	Quality of Life - Behavior control last week scale	The scale representing how often the participant found it hard to control his or her behavior in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLBehavrCntrlLastWkScl	Recommended	CDE
3	Quality of Life - Said without thinking last week scale	The scale representing how often the participant said or did things without thinking in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLSaidWithoutLstWkScl	Recommended	CDE
4	Quality of Life - Impatient with other people last week scale	The scale representing how often the participant became impatient with other people in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLImpatOthrPplLstWkScl	Recommended	CDE
5	Quality of Life - Irritable around other people last week scale	The scale representing how often the participant became irritable around other people in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLIritbleOthrPplLstWkScl	Recommended	CDE
6	Quality of Life - Bothered by little things last week scale	The scale representing how often the participant was bothered by little things in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLBothrdLtleThngLstWkScl	Recommended	CDE
7	Quality of Life - Upset easily last week scale	The scale representing how often the participant became easily upset in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLUpstEaslyLstWkScl	Recommended	CDE
8	Quality of Life - Conflict with others last week scale	The scale representing how often the participant was in conflict with others in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLCnflctWthOthrsLstWkScl	Recommended	CDE
9	Quality of Life - Impulsive last week scale	The scale representing how often the participant felt impulsive in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLImpulsiveLstWkScl	Recommended	CDE
10	Quality of Life - Talked loudly last week scale	The scale representing how often the participant was told by others that he or she talked in a loud or excessive manner in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLTalkedLoudlyLstWkScl	Recommended	CDE
11	Quality of Life - Said inappropriate things last week scale	The scale representing how often the participant said or did things that other people probably thought were inappropriate in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLSdInaprpteThngLstWkScl	Recommended	CDE
12	Quality of Life - Angry last week scale	The scale representing how often the participant felt angry in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLAngryLstWkScl	Recommended	CDE
13	Quality of Life - Emotional suddenly last week scale	The scale representing how often the participant suddenly became emotional for no reason in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLEmotnalSuddnlyLstWkScl	Recommended	CDE
14	Quality of Life - Restless last week scale	The scale representing how often the participant felt restless in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLRestlessLstWkScl	Recommended	CDE
15	Quality of Life - Hard to adjust last week scale	The scale representing how often the participant found it hard to adjust to unexpected changes in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLHardToAdjustLstWkScl	Recommended	CDE
16	Quality of Life -Hard time accepting criticism last week scale	The scale representing how often the participant had a hard time accepting criticism from other people in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLHrdTmeAcptCritLstWkScl	Recommended	CDE
17	Quality of Life - Stubborn with others last week scale	The scale representing how often the participant was stubborn with others in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLStubbornOthrsLstWkScl	Recommended	CDE
18	Quality of Life - Threatened violence last week scale	The scale representing how often the participant threatened violence toward people or property in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QOLThreatenedVioLstWkScl	Recommended	CDE

NeuroQol Scoring (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Quality of Life in Neurological Disorders (Neuro-Qol) - Items completed count	The count of items on the Neuro-Qol form completed by the participant, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QoLItemCompletedCount	Recommended	CDE
2	Quality of Life in Neurological Disorders (Neuro-Qol) - Long Form Raw score	The participant's raw score on the Neuro-Qol form, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QoLLFRawScore	Recommended	CDE
3	Quality of Life in Neurological Disorders (Neuro-Qol) - Standard error	Standard error, as part of the Quality of Life in Neurological Disorders (Neuro-Qol)	QoLStandardError	Recommended	CDE
4	Quality of Life in Neurological Disorders (Neuro-Qol) - T-score value	The value of the T-score, a standardized score with a mean of 50 and a standard deviation (SD) of 10 representing the rescaled raw score, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).(PROMIS).	QoLTScore	Recommended	CDE
5	Quality of Life in Neurological Disorders (Neuro-Qol) - Theta value	Theta metric value reported from the CAT Neuro-Qol results, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).	QoLThetaVal	Recommended	CDE

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