Form Structure: Neuro-QoL Pediatric Lower Extremity Function Short Form
This form structure is an organized set of data definitions for a copyrighted form
Title:
Neuro-QoL Pediatric Lower Extremity Function Short Form
Short Name:
NeuroQolPedLwrExtrmtySF
Description:
NeuroQoL Pediatric Lower 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:
Traumatic Brain Injury
General (For all diseases)
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 Lower Extremity Function SF (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Quality of Life - Kneel without hold scale | The scale which represents the extent to which the participant could get down on his or her knees without holding on to something, as part of Neuro-QOL Lower Extremity Function. | QoLKneelWithoutHoldScl | Recommended | CDE |
| 2 | Quality of Life - Keep up scale | The scale which represents the extent to which the participant could keep up when he or she played with other kids, as part of Neuro-QOL Lower Extremity Function. | QoLKeepUpScl | Recommended | CDE |
| 3 | Quality of Life - Walk 15 minute scale | The scale which represents the extent to which the participant could walk for 15 minutes, as part of Neuro-QOL Lower Extremity Function. | QoLWalkFifteenMinuteScl | Recommended | CDE |
| 4 | Quality of Life - Walk between room scale | The scale which represents the extent to which the participant could walk between rooms, as part of Neuro-QOL Lower Extremity Function. | QoLWalkBetweenRoomScl | Recommended | CDE |
| 5 | Quality of Life - Toilet on off scale | The scale which represents the extent to which the participant could get on and off the toilet without using his or her arms, as part of Neuro-QOL Lower Extremity Function. | QoLToiletOnOffScl | Recommended | CDE |
| 6 | Quality of Life - Chair on off scale | The scale which represents the extent to which the participant could get on and off a low chair, as part of Neuro-QOL Lower Extremity Function. | QoLChairOnOffScl | Recommended | CDE |
| 7 | Quality of Life - Floor up scale | The scale which represents the extent to which the participant could get up from the floor by myself, as part of Neuro-QOL Lower Extremity Function. | QoLFloorUpScl | Recommended | CDE |
| 8 | Quality of Life - Bench without support scale | The scale which represents the extent to which the participant could sit on a bench without support for 15 minutes, as part of Neuro-QOL Lower Extremity Function. | QoLBenchWithoutSupportScl | Recommended | CDE |
| 9 | Quality of Life - Tiptoes reach scale | The scale which represents the extent to which the participant could stand on my tiptoes to reach for something, as part of Neuro-QOL Lower Extremity Function. | QoLTiptoesReachScl | Recommended | CDE |
| 10 | Quality of Life - Tiptoes place scale | The scale which represents the extent to which the participant could stand on my tiptoes to put something (e.g., 5 lb bag of sugar) on a shelf, as part of Neuro-QOL Lower Extremity Function. | QoLTipotoesPlaceScl | Recommended | CDE |
| 11 | Quality of Life - Walk slight uneven scale | The scale which represents the extent to which the participant could walk on slightly uneven surfaces (such as cracked pavement), as part of Neuro-QOL Lower Extremity Function. | QoLWalkSlightUnevenScl | Recommended | CDE |
| 12 | Quality of Life - Walk rough uneven scale | The scale which represents the extent to which the participant could walk on rough, uneven surfaces (such as lawns, gravel driveway), as part of Neuro-QOL Lower Extremity Function. | QoLWalkRoughUnevenScl | Recommended | CDE |
| 13 | Quality of Life - Ramp up down scale | The scale which represents the extent to which the participant could walk up and down ramps or hills, as part of Neuro-QOL Lower Extremity Function. | QoLRampUpDownScl | Recommended | CDE |
| 14 | Quality of Life - Curb up down scale | The scale which represents the extent to which the participant could walk up and down curbs, as part of Neuro-QOL Lower Extremity Function. | QoLCurbUpDownScl | Recommended | CDE |
| 15 | Quality of Life - Bus in out scale | The scale which represents the extent to which the participant could get in and out of a bus, as part of Neuro-QOL Lower Extremity Function. | QoLBusInOutScl | Recommended | CDE |
| 16 | Quality of Life - Car in out scale | The scale which represents the extent to which the participant could get in and out of a car, as part of Neuro-QOL Lower Extremity Function. | QoLCarInOutScl | Recommended | CDE |
| 17 | Quality of Life - Walk across room scale | The scale which represents the extent to which the participant could walk across the room, as part of Neuro-QOL Lower Extremity Function. | QoLWalkAcrossRoomScl | Recommended | CDE |
| 18 | Quality of Life - Backpack walk scale | The scale which represents the extent to which the participant could walk while wearing a backpack full of books, as part of Neuro-QOL Lower Extremity Function. | QoLBackpackWalkScl | Recommended | CDE |
| 19 | Quality of Life - Bend over scale | The scale which represents the extent to which the participant could bend over to pick something up, as part of Neuro-QOL Lower Extremity Function. | QoLBendOvrScl | Recommended | CDE |
| 20 | Quality of Life - Exercise peers scale | The scale which represents the extent to which the participant could do exercise that others my age can do, as part of Neuro-QOL Lower Extremity Function. | QoLExercisePeersScl | 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 |
Keywords
