Form Structure: Screening Tool for Voice/Swallowing/Speech/Language
This form structure is an organized set of data definitions for a form that has not been copyrighted
Resource:
FITBIR
Title:
Screening Tool for Voice/Swallowing/Speech/Language
Short Name:
ScreeningToolVocSwlSpchLng
Description:
This screening instrument contains data elements that are collected to help in screening for post brain-injury problems related to voice, swallowing, speech and language.
Disease:
Traumatic Brain Injury
General (For all diseases)
Organization:
NIH/CIT/BRICS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-10-06
Owner:
Number of Data Elements:
19
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 |
Screening tool for voice/swallowing/speech/language (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Voice post-TBI problem indicator | Patient's response concerning problems with voice post-TBI. | VoicePostTBIProbInd | Recommended | CDE |
| 2 | Swallowing post-TBI problem indicator | Patient's response concerning problems with swallowing post-TBI. | SwallowingPostTBIProbInd | Recommended | CDE |
| 3 | Speech post-TBI problem indicator | Patient's response concerning problems with speech post-TBI. | SpeechPostTBIProbInd | Recommended | CDE |
| 4 | Language post-TBI problem indicator | Patient's response concerning problems with language post-TBI. | LangaugePostTBIProbInd | Recommended | CDE |
Keywords
