Form Structure: Neuro-QoL Pediatric Upper Extremity Function Short Form
This form structure is an organized set of data definitions for a copyrighted form
Title:
Neuro-QoL Pediatric Upper Extremity Function Short Form
Short Name:
NeuroQoLPedUpprExtrmtySF
Description:
NeuroQoL Pediatric Upper Extremity Function Short Form. Copyright 2008-2013 David Cella and the PROMIS Health Organization on behalf of the National Institute for Neurological Disorders and Stroke (NINDS)
Disease:
General (For all diseases)
Traumatic Brain Injury
Organization:
FITBIR
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-12-28
Owner:
Number of Data Elements:
41
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 |
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 |
Pediatric Upper Extremity Function SF (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Quality of Life - Point finger ability scale | The scale which represents the extent to which the participant was able to use his or her finger to point to something, as part of Neuro-QOL Upper Extremity. | QoLPointFingerAbilityScl | Recommended | CDE |
| 2 | Quality of Life - Take off sock ability scale | The scale which represents the extent to which the participant was able to take off his or her socks , as part of Neuro-QOL Upper Extremity. | QoLTakeOffSockAbilityScl | Recommended | CDE |
| 3 | Quality of Life - Fasten pants ability scale | The scale which represents the extent to which the participant was able to put on and fasten his or her pants by his or herslef, as part of Neuro-QOL Upper Extremity. | QoLFastenPantsAbilityScl | Recommended | CDE |
| 4 | Quality of Life - Button shirt ability scale | The scale which represents the extent to which the participant was able to button his or her own shirt, as part of Neuro-QOL Upper Extremity. | QoLButtonShirtAbilityScl | Recommended | CDE |
| 5 | Quality of Life - Bring food mouth ability scale | The scale which represents the extent to which the participant was able to use a spoon to bring food up to his or her mouth, as part of Neuro-QOL Upper Extremity. | QoLBringFoodMouthAbilityScl | Recommended | CDE |
| 6 | Quality of Life - Wipe ability scale | The scale which represents the extent to which the participant was able to wipe him or herslf thoroughly after using the toilet, as part of Neuro-QOL Upper Extremity. | QoLWipeAbilityScl | Recommended | CDE |
| 7 | Quality of Life - Pull up pants ability scale | The scale which represents the extent to which the participant was able to pull his or her pants back up after using the toilet, as part of Neuro-QOL Upper Extremity. | QoLPullUpPantsAbilityScl | Recommended | CDE |
| 8 | Quality of Life - Hold food plate ability scale | The scale which represents the extent to which the participant was able to hold a plate full of food, as part of Neuro-QOL Upper Extremity. | QoLHoldFoodPlateAbilityScl | Recommended | CDE |
| 9 | Quality of Life - Cut paper ability scale | The scale which represents the extent to which the participant was able tot cut a piece of paper in half with scissors, as part of Neuro-QOL Upper Extremity. | QoLCutPaperAbilityScl | Recommended | CDE |
| 10 | Quality of Life - Shower ability scale | The scale which represents the extent to which the participant was able to take a shower by him or herself, as part of Neuro-QOL Upper Extremity. | QoLShowerAbilityScl | Recommended | CDE |
| 11 | Quality of Life - Bath ability scale | The scale which represents the extent to which the participant was able to take a bath by him or herself, as part of Neuro-QOL Upper Extremity. | QoLBathAbilityScl | Recommended | CDE |
| 12 | Quality of Life - Key-pad phone call ability scale | The scale which represents the extent to which the participant was able to make a phone call using a touch tone key-pad, as part of Neuro-QOL Upper Extremity. | QoLKeypadPhoneCallAbilityScl | Recommended | CDE |
| 13 | Quality of Life - Out bed ability scale | The scale which represents the extent to which the participant was able to get out of bed by him or herself, as part of Neuro-QOL Upper Extremity. | QoLOutBedAbilityScl | Recommended | CDE |
| 14 | Quality of Life - Put on shoes ability scale | The scale which represents the extent to which the participant was able to put on my shoes by him or herself, as part of Neuro-QOL Upper Extremity. | QoLPutOnShoesAbilityScl | Recommended | CDE |
| 15 | Quality of Life - Open jar ability scale | The scale which represents the extent to which the participant was able to open a jar by him or herself, as part of Neuro-QOL Upper Extremity. | QoLOpenJarAbilityScl | Recommended | CDE |
| 16 | Quality of Life - Toothpaste toothbrush ability scale | The scale which represents the extent to which the participant was able to put toothpaste on a toothbrush by him or herself, as part of Neuro-QOL Upper Extremity. | QoLToothpstToothbrshAbilityScl | Recommended | CDE |
| 17 | Quality of Life - Brush teeth ability scale | The scale which represents the extent to which the participant was able to brush his or her teeth by him or herself, as part of Neuro-QOL Upper Extremity. | QoLBrushTeethAbilityScl | Recommended | CDE |
| 18 | Quality of Life - Dry back ability scale | The scale which represents the extent to which the participant was able to dry his or her back with a towel, as part of Neuro-QOL Upper Extremity. | QoLDryBackAbilityScl | Recommended | CDE |
| 19 | Quality of Life - Clothe self ability scale | The scale which represents the extent to which the participant was able to put on his or her clothes by him or herself, as part of Neuro-QOL Upper Extremity. | QoLClotheSelfAbiltyScl | Recommended | CDE |
| 20 | Quality of Life - Zip clothe ability scale | The scale which represents the extent to which the participant was able to zip up his or her clothes, as part of Neuro-QOL Upper Extremity. | QoLZipClotheAbilityScl | 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) - Raw score | The participant's raw score on the Neuro-Qol form, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLRawScore | 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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