Form Structure: Ohio State University TBI Identification Method Interview Form (OSUTBIMI)
This form structure is an organized set of data definitions for a form that has not been copyrighted
Resource:
FITBIR
Title:
Ohio State University TBI Identification Method Interview Form (OSUTBIMI)
Short Name:
OSUTBIMI
Description:
The Ohio State University (OSU) Traumatic Brain Injury (TBI) Identification Method (OSU TBI-ID) is a standardized procedure for eliciting a person?s lifetime history of TBI via a 3-5 minute structured interview. While not ideal for determining lifetime exposure to potentially damaging brain injury, self-report remains the gold standard for research and clinical use. The OSU TBI-ID has proven useful in many settings, including medical, mental health, substance abuse, domestic violence, corrections and aging. Health care and social service professionals need this tool to elicit a person?s history of TBI.
References: http://ohiovalley.org/tbi-id-method/clinical/
Form: https://osuwmcdigital.osu.edu/sitetool/sites/ohiovalleypublic/documents/OSU_TBIform_July2013.pdf
Disease:
Traumatic Brain Injury
Organization:
NIH
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2017-04-24
Version:
1.0
Date Created:
2016-03-18
Owner:
Number of Data Elements:
43
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 |
Step 1 (Repeat Infinitely)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever hospitalized after a head or neck injury indicator | Indicator of the subject ever being hospitalized or treated in an emergency room following an injury to their head or neck, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIEverHospAftrHeadInjInd | Recommended | CDE |
| 2 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever injured head or neck in a crash indicator | Indicator of the subject ever injuring their head or neck in a car accident or from crashing some other moving vehicle, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIEverInjHeadInCrashInd | Recommended | CDE |
| 3 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever injured head or neck in a fall or getting hit indicator | Indicator of the subject ever injuring their head or neck in a fall or from being hit by something, or from playing sports or on the playground, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIEverInjHeadFallHitInd | Recommended | CDE |
| 4 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever injured head or neck in a fight indicator | Indicator of the subject ever injuring their head or neck in a fight, from being hit, from being shaken violently, or from being shot in the head, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIEverInjHeadInFightInd | Recommended | CDE |
| 5 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever been near an explosion indicator | Indicator of the subject ever being nearby when an explosion or a blast occurred, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIEverNearExplosnInd | Recommended | CDE |
Step 2 (Appears Up To 22 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Hospitalized after a head or neck injury cause | Cause of the subject ever being hospitalized or treated in an emergency room following an injury to their head or neck, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIHospAftrHeadInjCause | Recommended | CDE |
| 2 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injured head or neck in a crash cause | Cause of the subject ever injuring their head or neck in a car accident or from crashing some other moving vehicle, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIInjHeadInCrashCause | Recommended | CDE |
| 3 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injured head or neck in a fall or getting hit cause | Cause of the subject ever injuring their head or neck in a fall or from being hit by something, or from playing sports or on the playground, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIInjHeadFallHitCause | Recommended | CDE |
| 4 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injured head or neck in a fight cause | Cause of the subject ever injuring their head or neck in a fight, from being hit, from being shaken violently, or from being shot in the head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIInjHeadInFightCause | Recommended | CDE |
| 5 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Near an explosion cause | Cause of the subject ever being nearby when an explosion or a blast occurred, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMINearExplosnCause | Recommended | CDE |
| 6 | Loss of consciousness indicator | The indicator for whether the participant/subject experienced any period of loss of consciousness (LOC). | LOCInd | Recommended | CDE |
| 7 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Loss of consciousness duration range | The range of duration of loss of consciousness the participant/subject experienced, as part of Ohio State University TBI Identification Method Interview Form (OSUTBIMI). | OSUTBIMILOCDurRang | Recommended | CDE |
| 8 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Dazed or memory gap from injury indicator | Indicator of the subject being dazed or having a gap in their memory from the injury, if they did not lose consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIDazedMemoryGapInjInd | Recommended | CDE |
| 9 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Loss of consciousness from injury age | Age of subject when they were knocked out, lost consciousness, dazed, or had gaps in their memory from the injury, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMILOCAge | Recommended | CDE |
Step 3 (Appears Up To 13 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Repeated head impacts indicator | Indicator of the subject ever having a period of time in which they experienced multiple, repeated impacts to their head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIRepeatHeadImpactInd | Recommended | CDE |
| 2 | Ohio State TBI Method Short Form (OSUTBIMS) - cause reason | The cause of the subject's injury as part of Ohio State TBI Method Short Form (OSUTBIMS). | OSUTBIMSCauseRsn | Recommended | CDE |
| 3 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Typical effect of repeated head injuries type | Type typical or usual effect of multiple, repeated impacts to the subject's head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMITypicalEffectInjTyp | Recommended | CDE |
| 4 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Dazed or memory gap from repeated head injuries indicator | Indicator of the subject being dazed or having a gap in their memory from the multiple, repeated impacts to their head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIDazeMemGapRepeatInjInd | Recommended | CDE |
| 5 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Most severe effect from head injury type | Type of most severe effect from one of the time the subject had an impact to the head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMISevereEffectInjTyp | Recommended | CDE |
| 6 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Repeated head injuries began age | Age of subject when repeated injuries began, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIRepeatHeadInjStartAge | Recommended | CDE |
| 7 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Repeated head injuries ended age | Age of subject when repeated injuries ended, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIRepeatHeadInjEndAge | Recommended | CDE |
| 8 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Additional injuries with loss of consciousness number | Number of additional injuries with loss of consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIAdditionalInjLOCNum | Recommended | CDE |
| 9 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Knocked out longest duration | Longest duration of being knocked out during additional injuries with loss of consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIKnockOutLongestDur | Recommended | CDE |
| 10 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injuries with loss of consciousness more than 30 minutes number | Number of additional injuries with loss of consciousness that lasted 30 minutes or more, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIInjLOC30PlusMinNum | Recommended | CDE |
| 11 | Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injuries with loss of consciousness youngest age | Youngest age subject had additional injuries with loss of consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) | OSUTBIMIInjLOCYoungestAge | Recommended | CDE |
Worst injury (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Traumatic event number | The number of traumatic event , which happened during the subject's life, as reported by the subject | TraumaticEventNum | Recommended | CDE |
| 2 | Ohio State TBI Method Short Form (OSUTBIMS) - worst injury result | Result to whether the subject has: 1 an improbable TBI , 2 a possible TBI , 3 a mild TBI , 4 a moderate TBI , or 5 a severe TBI as part of Ohio State TBI Method Short Form (OSUTBIMS) | OSUTBIMSWorstInjReslt | Recommended | CDE |
| 3 | Ohio State TBI Method Short Form (OSUTBIMS) - cause reason | The cause of the subject's injury as part of Ohio State TBI Method Short Form (OSUTBIMS). | OSUTBIMSCauseRsn | Recommended | CDE |
Keywords
