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Form Structure: Post-Traumatic Epilepsy Screening Form

This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
Post-Traumatic Epilepsy Screening Form
Short Name:
PostTraumaticEpilepsyScrn
Description:
The Post-Traumatic Epilepsy Screening form screens for post-traumatic epilepsy or seizures.References: NINDS CDE project, TBI https://www.commondataelements.ninds.nih.gov/TBI.aspx#tab=Data_Standards
Disease:
Traumatic Brain Injury
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-09-16
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 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.

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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

Post-Traumatic Epilepsy Screening Form (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Family member body uncontrolled movement indicator  Indicator for uncontrolled movements of part or all of the body such as twitching, jerking, shaking, or going limp, lasting about 5 minutes or less, that a family member has had or told you that you/they had FamMmberBodyUncntrlldMovmntInd Recommended CDE
2 Family member mental state awareness level unexplained change indicator  Indicator for an unexplained change in mental state or level of awareness; or an episode of "spacing out which you/your family member could not control, lasting about 5 minutes or less, that a family member has had or told you that you/they had FamMmbrMentlSteAwrnsLvlChngInd Recommended CDE
3 Family member repeated unusual attack or convulsion other type indicator  Indicator for any other type of repeated unusual attacks or convulsions lasting about 5 minutes or less that a family member has had or told you that you/they had FamMemRepUnuslAtkCnvlOthTypInd Recommended CDE
4 Family member seizures or epilepsy indicator  Indicator for someone having told you that you/your family member have seizures or epilepsy FamMembrSeizureEpilepsyInd Recommended CDE
5 Source of information queried type  Type of source of information queried SourceOfInformationQueriedTyp Recommended CDE
6 Pre traumatic brain injury seizure or epilepsy indicator  Indicator for seizures or epilepsy that the patient had prior to the traumatic brain injury PreTBISeizureEpilepsyInd Recommended CDE
7 Post traumatic brain injury diagnosis epilepsy seizure diagnosis indicator  Indicator for the diagnosis of the participant with epilepsy, a seizure disorder, or a single seizure after the date of the traumatic brain injury diagnosis PstTBIDiagEpilpSeizDiagInd Recommended CDE
8 Seven days post traumatic brain injury seizure occurrence indicator  Indicator for the occurrence of seizure(s) later than seven days after the date of the traumatic brain injury SevnDaysPstTBISeizOccurncInd Recommended CDE
9 Diagnosis first given date and time  Date (and time if applicable and known) the participant/subject was initially diagnosed with the disease or disorder DiagnosFirstGivnDateTime Recommended CDE
10 Diagnosis giver type  Type of professional who gave the diagnosis DiagnosisGiverTyp Recommended CDE
11 Seizure or epilepsy medication patient reception indicator  Indicator for the patient's reception of medication for seizures or epilepsy SeizEpilepMedicaPatntReceptInd Recommended CDE
Keywords

Change History