Form Structure: Neuro-QoL Pediatric Pain Short Form
This form structure is an organized set of data definitions for a copyrighted form
Title:
Neuro-QoL Pediatric Pain Short Form
Short Name:
NeuroQolPedPainSF
Description:
NeuroQoL Pediatric Pain 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:
31
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 Pain SF (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Quality of Life - Pain present high assessment scale | The scale representing how often the participant had lots of pain in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLPainPresentHighAssmtScl | Recommended | CDE |
| 2 | Quality of Life - Medicine needed assessment scale | The scale representing how often the participant's pain was so bad that he or she needed to take medicine for it in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLMedicineNeededAssmtScl | Recommended | CDE |
| 3 | Quality of Life - School missed assessment scale | The scale representing how often the participant missed school when he or she was in pain in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLSchoolMissedAssmtScl | Recommended | CDE |
| 4 | Quality of Life - Stop activity assessment scale | The scale representing how often the participant had so much pain that I had to stop what I was doing in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLStopActivityAssmtScl | Recommended | CDE |
| 5 | Quality of Life - Body pain assessment scale | The scale representing how often the participant hurt all over his or her body in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLBodyPainAssmtScl | Recommended | CDE |
| 6 | Quality of Life - Pain assessment scale | The scale representing how often the participant had pain in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLPainAssmtScl | Recommended | CDE |
| 7 | Quality of Life - Sleep difficulty assessment scale | The scale representing how often the participant had trouble sleeping when he or she had pain in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLSleepDifficltyAssmtScl | Recommended | CDE |
| 8 | Quality of Life - TV watching difficulty assessment scale | The scale representing how often the participant had trouble watching TV when he or she had pain in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLTvWatchingDifficltyAssmtScl | Recommended | CDE |
| 9 | Quality of Life - Play friend difficulty assessment scale | The scale representing how often the participant found it hard to play or hang out with his or her friends when he or she had pain in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLPlayFriendDffcltyAssmtScl | Recommended | CDE |
| 10 | Quality of Life - Pain length assessment scale | The scale representing how long the participant was in pain in the past 7 days, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). | QoLPainLngthAssmtScl | 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
