Form Structure: Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13)
This form structure is an organized set of data definitions for a form that has not been copyrighted
Resource:
FITBIR
Title:
Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13)
Short Name:
PCSISR13
Description:
The adolescent self-report form (PCSI-SR13) ages 13 to 18yrs contains 21 items, and responses were rated for severity on the 7-point Guttman dimensional scale. The following anchors were provided: 0 = Not a problem, 3 = Moderate problem, 6 = Severe problem. 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
Publication Date:
2018-03-13
Version:
1.1
Date Created:
2016-05-03
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 2 Times)
| # | 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 13-18yrs (PCSISR13) (Appears Up To 2 Times)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Headache scale | Scale to which the subject complained of headaches, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13HeadacheScl | Recommended | CDE |
| 2 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Nausea scale | Scale to which the subject complained of nausea, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13NauseaScl | Recommended | CDE |
| 3 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Balance problem scale | Scale to which the subject experienced balance problems, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13BalanceProbScl | Recommended | CDE |
| 4 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Dizziness scale | Scale to which the subject appeared or complained of dizziness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13DizzinessScl | Recommended | CDE |
| 5 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Fatigue scale | Scale to which the subject has fatigue, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13FatigueScl | Recommended | CDE |
| 6 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sleep more than usual scale | Scale to which the subject slept more than usual, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13SleepMoreThnUsualScl | Recommended | CDE |
| 7 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Drowsiness scale | Scale to which the subject experiences drowsiness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13DrowsinessScl | Recommended | CDE |
| 8 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sensitive to light scale | Scale to which the subject was sensitive to light, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13SensitiveToLightScl | Recommended | CDE |
| 9 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sensitive to noise scale | Scale to which the subject was sensitive to noise, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13SensitiveToNoiseScl | Recommended | CDE |
| 10 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Irritability scale | Scale to which the subject expressed irritability, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13IrritabilityScl | Recommended | CDE |
| 11 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sadness scale | Scale to which the subject expressed sadness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13SadnessScl | Recommended | CDE |
| 12 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Nervousness scale | Scale to which the subject expressed nervousness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13NervousnessScl | Recommended | CDE |
| 13 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Feeling more emotional scale | Scale to which the subject was feeling more emotional, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13FeelMoreEmotionalScl | Recommended | CDE |
| 14 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Feeling slowed down scale | Scale to which the subject was feeling slowed down, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13FeelSlowedDownScl | Recommended | CDE |
| 15 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Feeling mentally foggy scale | Scale to which the subject was feeling mentally foggy, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13MentallyFoggyScl | Recommended | CDE |
| 16 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Difficulty concentrating scale | Scale to which the subject had difficulty concentrating, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13DiffConcentrateScl | Recommended | CDE |
| 17 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Difficult remembering scale | Scale to which the subject had difficulty remembering, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13DiffRememberScl | Recommended | CDE |
| 18 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Visual problems scale | Scale to which the subject expressed visual problems (blurry, double vision), as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13VisualProbScl | Recommended | CDE |
| 19 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Get confused with directions or tasks scale | Scale to which the subject expressed getting confused with directions or tasks, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13ConfuWthDirctnsScl | Recommended | CDE |
| 20 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Clumsy scale | Scale to which the subject appeared to move in a clumsy manner, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13ClumsyScl | Recommended | CDE |
| 21 | Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Answer slowly scale | Scale to which the subject answered questions more slowly than usual, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). | PCSISR13AnswSlowlyScl | 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
