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

Resource:

FITBIR

Title:

Neuro-QoL Upper Extremity Function Short Form

Short Name:

NeuroQoLUppExtrmtySF

Description:

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:

2016-12-29

Owner:

Number of Data Elements:

29

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.

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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

Upper Extremity SF (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Quality of Life - Movement turn key lock ability scale	The scale which represents the extent to which the participant was able to turn a key in a lock, as part of Neuro-QOL Upper Extremity.	QoLMoveTurnKeyLockAbilityScl	Recommended	CDE
2	Quality of Life - Movement brush teeth ability scale	The scale which represents the extent to which the participant was able to brush their teeth, as part of Neuro-QOL Upper Extremity.	QoLMoveBrushTeethAblityScl	Recommended	CDE
3	Quality of Life - Movement touch-tone 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.	QolMoveTouchTneCallAbilityScl	Recommended	CDE
4	Quality of Life - Movement pick up coin ability scale	The scale which represents the extent to which the participant was able to pick up coins from a table top, as part of Neuro-QOL Upper Extremity.	QoLMovePckUpCoinAbltyScl	Recommended	CDE
5	Quality of Life - Movement pen pencil write ability scale	The scale which represents the extent to which the participant was able to write with a pen or pencil, as part of Neuro-QOL Upper Extremity.	QolMovePenPenclWrteAbilityScl	Recommended	CDE
6	Quality of Life - Movement zipper open close ability scale	The scale which represents the extent to which the participant was able to open and close a zipper, as part of Neuro-QOL Upper Extremity.	QoLMoveZipprOpnClseAblityScl	Recommended	CDE
7	Quality of Life - Movement body wash dry ability scale	The scale which represents the extent to which the participant was able to wash and dry their body, as part of Neuro-QOL Upper Extremity.	QoLMoveBodyWashDryAblityScl	Recommended	CDE
8	Quality of Life - Movement shampoo hair ability scale	The scale which represents the extent to which the participant was able to shampoo their hair, as part of Neuro-QOL Upper Extremity.	QoLMoveShampooHairAbilityScl	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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