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Form Structure: Posttraumatic Stress Disorder Checklist (PCL) Civilian Version

This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
Posttraumatic Stress Disorder Checklist (PCL) Civilian Version
Short Name:
PCLC_Standard
Description:
The Posttraumatic Stress Disorder Checklist (PCL) Civilian Version is a 17-item self-reported measure composed of the DSM-IV symptoms of Posttraumatic Stress Disorder[ (PTSD). Respondents rate on a five-point scale how much they were bothered by each symptom "in the past month." The PCL-C (Civilian) is not focused on any one traumatic event. For more information, refer to http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp Recommended by CDISC for TBI
Disease:
Traumatic Brain Injury
Organization:
NIH
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2014-09-26
Version:
1.3
Date Created:
2014-08-25
Owner:
Number of Data Elements:
26
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 Visit date   Actual interview or visit date VisitDate Recommended CDE
5 Site name   The name of the site for the study SiteName Recommended CDE
6 Days since baseline   The number of days since baseline DaysSinceBaseline Optional CDE
7 Case control indicator   Indicator of whether subject is in the case or control arm of the study. CaseContrlInd Optional CDE
8 General notes text   General notes GeneralNotesTxt Optional CDE

Additional Element Groups

Listed below are your additional element groups.

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Questions (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 PTSD Checklist Stressor (PCLS) - Memories indicator  Indicator how often the subject has repeated, disturbing memories thoughts, or images of a stressful experience as part of PTSD Checklist Military (PCLM). PCLSMemoriesInd Recommended CDE
2 PTSD Checklist Stressor (PCLS) - Dreams indicator  Indicator whether the subject has repeated, disturbing dreams of the stressful experience as part of PTSD Checklist Stressor (PCLS). PCLSDreamsInd Recommended CDE
3 PTSD Checklist Stressor (PCLS) - Happen again indicator  Indicator of how often the subject suddenly acts or feels as if the stressful experience were happening against (as if he or she was reliving it) as part of PTSD Checklist Stressor (PCLS). PCLSHappenAgainInd Recommended CDE
4 PTSD Checklist Stressor (PCLS) - Very upset indicator  Indicator how often the subject feels very upset when something reminds he or she of the stressful experience as part of PTSD Checklist Stressor (PCLS). PCLSVeryUpsetInd Recommended CDE
5 PTSD Checklist Stressor (PCLS) - Physical reaction indicator  Indicator how often the subject has physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded he or she of the stressful experience as part of PTSD Checklist Stressor (PCLS). PCLSPhysicalReactionsInd Recommended CDE
6 PTSD Checklist Stressor (PCLS) - Avoid having feeling indicator  Indicator how often the subject avoids thinking about or talking about the stressful experience or avoiding having feelings related to it as part of PTSD Checklist Stressor (PCLS). PCLSAvoidHavingFeelingInd Recommended CDE
7 PTSD Checklist Stressor (PCLS) - Avoid situation indicator  Indicator how often the subject avoids activities or situations because they remind he or she of the stressful experience as part of PTSD Checklist Stressor (PCLS). PCLSAvoidSituationInd Recommended CDE
8 PTSD Checklist Stressor (PCLS) - Remember important indicator  Indicator how often the subject has trouble remembering important parts of a stressful experience as part of PTSD Checklist Stressor (PCLS). PCLSRememberImportantInd Recommended CDE
9 PTSD Checklist Stressor (PCLS) - Loss interest indicator  Indicator how often the subject has a loss of interest in activities that he or she used to enjoy as part of PTSD Checklist Stressor (PCLS). PCLSLossInterestInd Recommended CDE
10 PTSD Checklist Stressor (PCLS) - Feel distant indicator  Indicator how often the subject feels distant or cut off from other people as part of PTSD Checklist Stressor (PCLS). PCLSFeelDistantInd Recommended CDE
11 PTSD Checklist Stressor (PCLS) - Emotionally numb indicator  Indicator how often the subject feels emotionally numb or feels unable to have loving feelings for those he or she is close to as part of PTSD Checklist Stressor (PCLS). PCLSEmotionallyNumbInd Recommended CDE
12 PTSD Checklist Stressor (PCLS) - Short future indicator  Indicator how often the subject feels as if his or her future will somehow be cut short as part of PTSD Checklist Stressor (PCLS). PCLSShortFutureInd Recommended CDE
13 PTSD Checklist Stressor (PCLS) - Fall stay asleep indicator  Indicator how often the subject has trouble falling or staying asleep as part of PTSD Checklist Stressor (PCLS). PCLSFallStayAsleepInd Recommended CDE
14 PTSD Checklist Stressor (PCLS) - Angry outburst indicator  Indicator how often the subject feels irritable or has angry outbursts as part of PTSD Checklist Stressor (PCLS). PCLSAngryOutburstInd Recommended CDE
15 PTSD Checklist Stressor (PCLS) - Difficulty concentrating indicator  Indicator how often the subject has difficulty concentrating as part of PTSD Checklist Stressor (PCLS). PCLSDifficultyConcentratingInd Recommended CDE
16 PTSD Checklist Stressor (PCLS) - Super alert indicator  Indicator how often the subject feels "super-alert" or watchful as part of PTSD Checklist Stressor (PCLS). PCLSSuperAlertInd Recommended CDE
17 PTSD Checklist Stressor (PCLS) - Jumpy indicator  Indicator how often the subject feels jumpy or easily startled as part of PTSD Checklist Stressor (PCLS). PCLSJumpyInd Recommended CDE
18 PTSD Checklist Civilian (PCL - C) - Total score  A total score (range 17-85) can be obtained by summing the scores from each of the 17 items, as part of PTSD Checklist Civilian (PLC-C). PCLCTotlScore Recommended CDE
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