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Form Structure: Substance Abuse Questions from the TBI Model Systems Database

This form structure is an organized set of data definitions for a copyrighted form
Resource:
FITBIR
Title:
Substance Abuse Questions from the TBI Model Systems Database
Short Name:
SubstanceAbuseQuestnTBIMS
Description:
One item queries use of non-prescription or illicit drugs within past year. Two optional items ask for the specific drugs used, and the frequency of use of each drug. Four items assess quantity and frequency of alcohol use in past month, and extent of binge drinking.
Disease:
Traumatic Brain Injury
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-03-30
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

Substance Abuse Questions TBIMS (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Illicit drugs indicator  Indicator of subject's use of illicit drugs as part of the Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD). SAQTBIMSDillctDrgInd Recommended CDE
2 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Drugs used type  Type of drugs used by the subject as part of the Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD). SAQTBIMSDDrgUsdInd Recommended CDE
3 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Drugs used other text  The free-text field related to 'Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Drugs used indicator' specifying other text. Indicator of illicit drugs used by the subject. SAQTBIMSDDrgUsdOTH Recommended CDE
4 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Alcoholic beverage consumption status  Checking alcohol consumption status of the subject as part of the Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD). SAQTBIMSDAlcBevConsumpStatus Recommended CDE
5 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Alcoholic beverage consumption day week frequency  Frequency of days subject consumes alcohol as part of the Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD). SAQTBIMSDAlcBevConsumpDyWkFreq Recommended CDE
6 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Alcoholic beverage consumption average value  Number of alcoholic beverages the subject consumes on average on the days he/she drank as part of the Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD). SAQTBIMSDAlcBevConsumpAvgVal Recommended CDE
7 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Alcoholic beverage consumption month five frequency  Frequency of days the subject drank more than 5 drinks on an occasion as part of the Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD). SAQTBIMSDAlcBevConsumpMth5Freq Recommended CDE
8 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Drinks Per Week Score  Score for drinks taken per week, as a part of Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) SAQTBIMSDrnksPerWkScore Recommended CDE
9 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Alcohol Use Category  Category for alcohol use, as a part of Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) SAQTBIMSAlcoholUseCat Recommended CDE
10 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Problem Use Category  Category for problem use, as a part of Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) SAQTBIMSProblemUseCat Recommended CDE
11 Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) - Binge Drinker Type  Type of Binge Drinker, as a part of Substance Abuse Questions from the TBI Model Systems Database (SAQTBIMSD) SAQTBIMSBingeDrinkerTyp Recommended CDE
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