Form Structure: Post-Concussion Symptom Inventory - Self Report 5y-7y and 8y-12y(PCSI-SR)
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
Post-Concussion Symptom Inventory - Self Report 5y-7y and 8y-12y(PCSI-SR)
Short Name:
PCSISR
Description:
The older child self-report form for ages 8 to12 years (PCSI-SR8) contains 17 items, and responses were simplified and rated for severity to a 3-point Guttman scale (0 = No, 1 = A little, 2 = A lot). The younger child self-report form for ages 5 to 7 years (PCSI-SR5) contains 5 items, and responses were simplified and rated for severity to a 3-point Guttman scale (0 = No, 1 = A little, 2 = A lot). References: Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, https://www.ncbi.nlm.nih.gov/books/NBK185341/ Recommended by CDISC for TBI (TAUG TBI)
Disease:
Traumatic Brain Injury
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-05-03
Owner:
Number of Data Elements:
42
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 (Repeat Infinitely)
| # | 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 |
PCSI Self Report 8y-12y (PCSISR8) (Appears Up To 2 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Headache scale | Scale to which the subject complained of having headaches or head hurting, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRHeadacheScale | Recommended | CDE |
| 2 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Sick in stomach/Nausea scale | Scale to which the subject complained of feeling sick to their stomach or being nauseaous, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltSickStomachScale | Recommended | CDE |
| 3 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Balance problem scale | Scale to which the subject experienced balance problems, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRBalanceProbScale | Recommended | CDE |
| 4 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt dizzy scale | Scale to which the subject has felt dizzy, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltDizzyScale | Recommended | CDE |
| 5 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - More Tired Than Usual scale | Scale to which the subject has felt more tired than usual, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRMoreTiredThanUsualScale | Recommended | CDE |
| 6 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt more drowsy or sleepy than usual scale | Scale to which the subject has felt more drowsy or sleepy than usual, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltDrowsySleepyScale | Recommended | CDE |
| 7 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Bright light bother more than usual scale | Scale to which the subject expressed that bright lights have bothered them more than usual, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRBrightLightBotherScale | Recommended | CDE |
| 8 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Loud noises bother scale | Scale to which the subject was sensitive to noise, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRLoudNoiseBotherScale | Recommended | CDE |
| 9 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt grumpy or irritability scale | Scale to which the subject felt grumpy or irritable, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltGrumpyScale | Recommended | CDE |
| 10 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt sad scale | Scale to which the subject has felt sad, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltSadScale | Recommended | CDE |
| 11 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt nervous or worried scale | Scale to which the subject has felt nervous or worried, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltNervousWorriedScale | Recommended | CDE |
| 12 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt like moving more slowly scale | Scale to which the subject was feeling like they were moving more slowly, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRMovingMoreSlowlyScale | Recommended | CDE |
| 13 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Thinking more slowly scale | Scale to which the subject felt that they were thinking more slowly, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRThinkMoreSlowScale | Recommended | CDE |
| 14 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to think clear scale | Scale to which the subject felt that it has been hard to think, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRHardThinkClearScale | Recommended | CDE |
| 15 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to pay attention scale | Scale to which the subject expressed that it has been hard for them to pay attention to what they are doing, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRHardPayAttentionScale | Recommended | CDE |
| 16 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to remember things scale | Scale to which the subject has found it hard to remember things, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRHardRememberThingsScale | Recommended | CDE |
| 17 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Things look blurry scale | Scale to which the subject expressed that things looked blurry, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRLookBlurryScale | Recommended | CDE |
PCSI Self Report 5y-7y (PCSISR5) (Appears Up To 2 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Headache scale | Scale to which the subject complained of having headaches or head hurting, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRHeadacheScale | Recommended | CDE |
| 2 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Sick in stomach/Nausea scale | Scale to which the subject complained of feeling sick to their stomach or being nauseaous, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltSickStomachScale | Recommended | CDE |
| 3 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt dizzy scale | Scale to which the subject has felt dizzy, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltDizzyScale | Recommended | CDE |
| 4 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt grumpy or irritability scale | Scale to which the subject felt grumpy or irritable, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRFeltGrumpyScale | Recommended | CDE |
| 5 | Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to pay attention scale | Scale to which the subject expressed that it has been hard for them to pay attention to what they are doing, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). | PCSISRHardPayAttentionScale | Recommended | CDE |
PCSI Scoring (Appears Up To 2 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Post-Concussion Symptom Inventory - Physical Factor Subscale Summary Score | Score of the Physical Content-based factors, as a part of the Post-Concussion Symptom Inventory PCSI | PCSIPhysicalSymptomSubsclScore | Recommended | CDE |
| 2 | Post-Concussion Symptom Inventory - Cognitive Factor Subscale Summary Score | Score of the Cognitive Content-based factor subscale, as a part of the Post-Concussion Symptom Inventory PCSI | PCSICognitiveSymptmSubsclScore | Recommended | CDE |
| 3 | Post-Concussion Symptom Inventory - Emotional Factor Subscale Summary Score | Score of the Emotional Content-based factor subscale, as a part of the Post-Concussion Symptom Inventory PCSI | PCSIEmotionalSymptmSubsclScore | Recommended | CDE |
| 4 | Post-Concussion Symptom Inventory - Fatigue Factor Subscale Summary Score | Score of the Fatigue Content-based factor subscale, as a part of the Post-Concussion Symptom Inventory PCSI | PCSIFatigueSymptomSubsclScore | Recommended | CDE |
| 5 | Post-Concussion Symptom Inventory - Total Score | Total score, as a part of the Post-Concussion Symptom Inventory PCSI | PCSITotalScore | Recommended | CDE |
Keywords
