Form Structure: Pediatric Quality of Life Inventory(PedsQL) Family Impact Module
This form structure is an organized set of data definitions for a copyrighted form
Resource:
FITBIR
Title:
Pediatric Quality of Life Inventory(PedsQL) Family Impact Module
Short Name:
PedsQLFamImpMod
Description:
The PedsQL 4.0 Measurement Model is a modular approach to measuring health-related quality of life (HRQOL) in healthy children and adolescents and those with acute and chronic health conditions. The Parent report of the PedsQL Family Impact Module is composed of 36 items comprising 8 dimensions. opyright 1998 JW Varni, PhD. All rights reserved. Varni JW, Seid M, Kurtin PD. PedsQL 4.0: Reliability and validity of the pediatric quality of life inventory Version 4.0 generic core scales in healthy and patient populations. Medical Care. 2001; 38(8): 800-12.
Disease:
General (For all diseases)
Traumatic Brain Injury
Organization:
NIH/CIT/BRICS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-11-02
Owner:
Number of Data Elements:
54
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 |
PedsQL Physical Functioning (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Physical functioning tired day scale | Scale of how often the parent feels tired during the day, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMPhysFnctngTiredDayScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Physical functioning morning awake tired scale | Scale of how often the parent feels tired when he or she wakes up in the morning, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMPhysFnctngMrnAwkScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Physical functioning tired like scale | Scale of how often the parent feels too tired to do the things he or she likes to do, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMPhysFnctngTiredLkScl | Recommended | CDE |
4 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Physical functioning headache scale | Scale of how often the parent gets headaches, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMPhysFnctngHeadacheScl | Recommended | CDE |
5 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Physical functioning physically weak scale | Scale of how often the parent feels physically weak, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMPhysFnctngPhysWeakScl | Recommended | CDE |
6 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Physical functioning sick stomach scale | Scale of how often the parent feels sick to his or her stomach, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMPhysFnctngSckStmchScl | Recommended | CDE |
PedsQL FIM Emotional Functioning (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Emotional functioning anxious scale | Scale of how often the parent feels anxious, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMEmoFnctngAnxiousScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Emotional functioning sad scale | Scale of how often the parent feels sad, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMEmoFnctngSadScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Emotional functioning angry scale | Scale of how often the parent feels angry, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMEmoFnctngAngryScl | Recommended | CDE |
4 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Emotional functioning frustrated scale | Scale of how often the parent feels frustrated, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMEmoFnctngFrstrtdScl | Recommended | CDE |
5 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Emotional functioning helpless hopeless scale | Scale of how often the parent feels helpless or hopeless, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMEmoFnctngHlplsHplsScl | Recommended | CDE |
PedsQL FIM Social Functioning (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Social functioning isolated others scale | Scale of how often the parent feel isolated from others, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMSocFnctngIsoltdOthScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Social functioning trouble getting support scale | Scale of how often the parent has trouble getting support from others, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMSocFnctngGtngSprtScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Social functioning hard finding time scale | Scale of how often the parent finds it hard to find time for social activities, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMSocFnctngHrdFndgTmScl | Recommended | CDE |
4 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Social functioning not enough energy scale | Scale of how often the parent does not have energy for social activities, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMSocFnctngNtEngEnrgScl | Recommended | CDE |
PedsQL FIM Cognitive Functioning (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Cognitive functioning hard pay attention scale | Scale of how often the parent finds it hard to keep his or her attention on things, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMCogFnctHrdPyAttnScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Cognitive functioning hard remember people tell me scale | Scale of how often the parent finds it hard to remember what people have just told them, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMCogFnctHrdRmbPplTlScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Cognitive functioning hard remember heard scale | Scale of how often the parent finds it hard to remember what he or she just heard, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMCogFnctHrdRmbrHrdScl | Recommended | CDE |
4 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Cognitive functioning hard think quick scale | Scale of how often the parent finds it hard to think quickly, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMCogFnctHrdThnkQckScl | Recommended | CDE |
5 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Cognitive functioning trouble remember thought scale | Scale of how often the parent has trouble remembering what he or she was just thinking, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module.. | PedsQLFIMCogFnctTrbRmbrThgtScl | Recommended | CDE |
PedsQL FIM Communication (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Communication other people not understand scale | Scale of how often the parent feels that others do not understand his families situation, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMCommOthDntUndrstndScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Communication hard talk with other people scale | Scale of how often the parent finds it hard to talk about his or her child's health with others, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMCommHrdTlkWthOthrScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Communication hard tell doctor scale | Scale of how often the parent finds it hard to tell doctors and nurses how he or she feels, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMCommHardTellDctrScl | Recommended | CDE |
PedQL FIM Worry (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Worry treatment working scale | Scale of how often the parent worries about whether or not his or her child's medical treatments are working, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMWrryTrtmntWrkngScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Worry treatment side effect scale | Scale of how often the parent worries about the side effects of his or her child's medications/medical treatment, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMWrryTrtmntSidEffctScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Worry other people react scale | Scale of how often the parent worries about how others will react to his or her child's condition, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMWrryOtherPplReactScl | Recommended | CDE |
4 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Worry affecting family scale | Scale of how often the parent worries about how his or her child's illness is affecting other family members,as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMWrryAffctngFamilyScl | Recommended | CDE |
5 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Worry child future scale | Scale of how often the parent worries about his or her child's future, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMWrryChildFutureScl | Recommended | CDE |
PedsQL FIM Daily Activities (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Daily activity family activity more effort scale | Scale of how often family activities take more time and effort, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMDlyActvFmActvMrEffScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Daily activity difficulty finish household task scale | Scale of how often families have difficulty finding time to finish household tasks, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMDlyActvDfcltFnsTskScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Daily activity too tired to finish household task scale | Scale of how often the family feels too tired to finish household task, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMDlyActvTrdFnshTskScl | Recommended | CDE |
PedsQL FIM Family Relationships (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Family relations lack communication scale | Scale of how often the family lacks communication between family members, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMFamRltnLckComnctnScl | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Family relations family conflict scale | Scale of how often there are conflicts between family members, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMFamRltnFamCnflctScl | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Family relations difficulty make decision scale | Scare of how often the family has difficulties making decisions together as a family, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMFamRltnDfctyMkDcsnScl | Recommended | CDE |
4 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Family relations difficulty solve problem scale | Scale of how often the family has difficulties solving family problems together, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMFamRltnDifctSlvPrbScl | Recommended | CDE |
5 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Family relations family stress scale | Scale of how often the family experiences stress or tension between family members, as part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMFmlyRltnStressScl | Recommended | CDE |
PedsQL FIM Scoring (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Pediatric Quality of Life Inventory(PedsQL) - Total Score | Total Score as a part of Pediatric Quality of Life Inventory (PedsQL). | PedsQLTtlScore | Recommended | CDE |
2 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Parent HRQL Summary Score | Summary score for physical, emotional, social, and cognitive functioning scales, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMPrtHRQLSumScore | Recommended | CDE |
3 | Pediatric Quality of Life Inventory (PedsQL) Family Impact Module - Family Functioning Summary Score | Summary score for daily activities and family relationships scales, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module. | PedsQLFIMFamilyFunctnSumScore | Recommended | CDE |
Keywords