Form Structure: Neuro-QoL Lower Extremity Function Long Form : FITBIR : Federal Interagency Traumatic Brain Injury Research Informatics System

Form Structure: Neuro-QoL Lower Extremity Function Long Form

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

Title:

Neuro-QoL Lower Extremity Function Long Form

Short Name:

NeuroQoLLwrExtrmtyFnctnLF

Description:

Disease:

General (For all diseases) Traumatic Brain Injury

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

Lower Extremity Function LF (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Quality of Life - Movement sit stand toilet seat scale	The scale which represents the extent to which the participant was able to get on and off the toilet, as part of Neuro-QOL Lower Extremity Function.	QoLMoveSitStndToiletSeatScl	Recommended	CDE
2	Quality of Life - Movement up down step curb ability scale	The scale which represents the extent to which the participant was able to step up and down curbs, as part of Neuro-QOL Lower Extremity Function.	QolMoveUpDownStepCurbAbltyScl	Recommended	CDE
3	Quality of Life - Movement in out car ability scale	The scale which represents the extent to which the participant was able to get in and out of the car, as part of Neuro-QOL Lower Extremity Function.	QolMoveInOutCarAbilityScl	Recommended	CDE
4	Quality of Life - Movement bed chair ability scale	The scale which represents the extent to which the participant was able to get out of bed into a chair, as part of Neuro-QOL Lower Extremity Function.	QolMoveBedChairAbilityScl	Recommended	CDE
5	Quality of Life - Movement push open heavy door ability scale	The scale which represents the extent to which the participant was able to push open a heavy door, as part of Neuro-QOL Lower Extremity Function.	QolMovePshOpnHvyDoorAblityScl	Recommended	CDE
6	Quality of Life - Movement errand shop ability scale	The scale which represents the extent to which the participant was able to run errands and shop, as part of Neuro-QOL Lower Extremity Function.	QolMoveErrandShopAbilityScl	Recommended	CDE
7	Quality of Life - Movement without assistance floor stand ability scale	The scale which represents the extent to which the participant was able to get up off the floor from lying on their back without help, as part of Neuro-QOL Lower Extremity Function.	QolMoveWthoutAsstnFlrAbltyScl	Recommended	CDE
8	Quality of Life - Movement walk fifteen minute duration ability scale	The scale which represents the extent to which the participant was able to go for a walk of at least 15 minutes, as part of Neuro-QOL Lower Extremity Function.	QolMoveWlkFftnMinDurAbltyScl	Recommended	CDE
9	Quality of Life - Movement armless straight chair stand up difficulty scale	The scale which represents the amount of difficulty the participant currently has in standing up from an armless straight chair (e.g., dining room chair), as part of Neuro-QOL Lower Extremity Function.	QoLMoveArmlssStrghtChrAbltyScl	Recommended	CDE
10	Quality of Life - Movement chair sit stand difficulty scale	The scale which represents the amount of difficulty the participant currently has in sitting down on and standing up from a chair with arms, as part of Neuro-QOL Lower Extremity Function.	QolMoveChrSitStndDifAbltyScl	Recommended	CDE
11	Quality of Life - Movement bed sit lay down difficulty scale	The scale which represents the amount of difficulty the participant currently has in moving from sitting at the side of the bed to lying down on their back, as part of Neuro-QOL Lower Extremity Function.	QolMoveBedSitLayDownDiffScl	Recommended	CDE
12	Quality of Life - Movement low soft couch stand difficulty scale	The scale which represents the amount of difficulty the participant currently has in standing up from a low, soft couch, as part of Neuro-QOL Lower Extremity Function.	QoLMoveLowSoftCouchStndDiffScl	Recommended	CDE
13	Quality of Life - Movement flight stair handrail up down difficulty scale	The scale which represents the amount of difficulty the participant currently has in going up and down a flight of stairs inside, using a handrail, as part of Neuro-QOL Lower Extremity Function.	QolMoveFlghtStrUpDwnDiffScl	Recommended	CDE
14	Quality of Life - Movement uneven surface walk difficulty scale	The scale which represents the amount of difficulty the participant currently has in walking on uneven surfaces (e.g., grass, dirt road or sidewalk), as part of Neuro-QOL Lower Extremity Function.	QolMoveUnevenSrfaceWlkDiffScl	Recommended	CDE
15	Quality of Life - Movement single floor walk difficulty scale	The scale which represents the amount of difficulty the participant currently has in walking around one floor of their home, as part of Neuro-QOL Lower Extremity Function.	QolMoveSingleFloorWalkDiffScl	Recommended	CDE
16	Quality of Life - Movement twenty minute duration brisk walk difficulty scale	The scale which represents the amount of difficulty the participant currently has in taking a 20-minute brisk walk, without stopping to rest, as part of Neuro-QOL Lower Extremity Function.	QoLMoveTwtyMnDrtnBrskWkDiffScl	Recommended	CDE
17	Quality of Life - Movement outdoor slippery surface walk difficulty scale	The scale which represents the amount of difficulty the participant currently has in walking on a slippery surface, outdoors, as part of Neuro-QOL Lower Extremity Function.	QoLMoveOutdrSlprySrfcWkDiffScl	Recommended	CDE
18	Quality of Life - Movement no handrail stair climb difficulty scale	The scale which represents the amount of difficulty the participant currently has in climbing stairs step over step without a handrail (alternating feet), as part of Neuro-QOL Lower Extremity Function.	QoLMoveNoHandrlStrClmbDiffScl	Recommended	CDE
19	Quality of Life - Movement dark room no fall walk difficulty scale	The scale which represents the amount of difficulty the participant currently has in walking in a dark room without falling, as part of Neuro-QOL Lower Extremity Function.	QoLMoveDrkRmNoFallWalkDiffScl	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

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

Keywords

Change History