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Form Structure: TBIMS Form II Follow-Up

This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
TBIMS Form II Follow-Up
Short Name:
TBIMS_Form_II
Description:
Form II is the longitudinal follow-up component of the TBIMS. Most of the standardized outcome measures included in Form II have been submitted to FITBIR individually (i.e. FIM, DRS, PART-O, GOS-E, and QOL). The variables included in the TBIMS_Form_II table consist primarily of administrative (Vital Status, Follow-Up Status, etc.), demographic (Marital Status, Residence Type, etc.), and psychosocial (Drug Use, Alcohol Use, etc.) elements from the Form II longitudinal follow-up.
Disease:
Traumatic Brain Injury
Organization:
NIH/CIT/BRICS
Required Program Form:
No
Standardization:
Unique
Labels:
Form Type:
Clinical Assessment
Publication Date:
2017-09-27
Version:
1.0
Date Created:
2017-09-22
Owner:
Number of Data Elements:
76
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.

Collapse All   Expand All

Form Administration (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Context type  The context to which the questions were answered ContextType Recommended CDE
2 Context type other text  The free-text related to ContextType specifying other text ContextTypeOTH Recommended CDE
3 Data source  Source of the data provided on the case report form DataSource Recommended CDE
4 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

Form II Administrative (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Participation status type  Participation status at follow-up ParticipationStatusTyp Recommended UDE
2 Data capture method type  The type of method used to capture the data collected for the survey DataCaptureMethodTyp Recommended UDE
3 Missing data reason type  Type of reason data is missing by participant/subject MissingDataReasonTyp Recommended UDE
4 Death date and time  Date (and time, if known) of participant's/subject's death DeathDateTime Recommended CDE

Death cause (Appears Up To 2 Times)

# Title Short Description Variable Name Required? Type
1 Death cause ICD-9-CM code  ICD-9-CM code that describes the cause of participant/subject's death DeathCauseICD9CMCode Recommended CDE
2 Death cause ICD-9-CM E code 

(Deprecated)

 		External cause of death ICD-9 Code DeathCauseICD9CMECode Recommended UDE

Form II demographics (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Residence type  Type of residence ResidenceTyp Recommended UDE
2 ZIP partial code  First three digits of the zip code where the participant/subject currently lives. ZIPPartialCode Recommended CDE
3 Residence type other text  The free-text related to �ResidenceTyp' specifying other text ResidenceTypOTH Recommended UDE
4 Current address duration  Duration, in months, the participant has lived at their current address CurrentAddressDur Recommended UDE
5 Living situation of an adult subject  Living situation of an adult subject, including the primary person living with adult subject information SesPrimAdult Recommended CDE
6 Other primary person living with adult patient  Other Primary person living with adult patient SesPrimAdultOther Recommended CDE
7 Marital or partner status  Status of participant/subjects current domestic relationship, whether marital or partnered MartlPartnerStatus Recommended CDE
8 Marital or partner status other text  The free-text field related to Marital or partner status specifying other text. Status of participant/subjects current domestic relationships. MartlPartnerStatusOTH Recommended CDE
9 Marital or partner status change type  Type of change in status of participant/subjects current domestic relationship since last follow-up MartlChangeTyp Recommended UDE
10 Ethnicity USA category  Category of ethnicity the participant/subject most closely identifies with EthnUSACat Recommended CDE
11 Race USA category  The subject self declared racial origination, independent of ethnic origination, using OMB approved categories. RaceUSACat Recommended CDE
12 Language primary ISO code  Code (ISO 639-2 alpha-3 code) for the language the participant/subject speaks most often. LangPrimryTxt Recommended CDE
13 Language primary other text  The free-text field related to Language primary text specifying other text. Text for the language the participant/subject speaks most often LangPrimryOTH Recommended CDE
14 Birth country ISO code  Code (ISO 3166-1 alpha-2 code) for country where the participant/subject was born BirthCntryISOCode Recommended CDE
15 Birth country name  Name for country where the participant/subject was born BirthCntryName Recommended CDE
16 Years in USA number  The number of years that a participant has lived in the United States YearsInUSANum Recommended UDE
17 Education level USA type  Highest grade or level of school participant/subject has completed or the highest degree received EduLvlUSATyp Recommended CDE
18 Education level text  Text describing the highest grade or level of school participant/subject has completed or the highest degree received EduLvlText Recommended UDE
19 General Education Diploma (GED) indicator  Indicator the participant/subject has a General Education Diploma (GED) GEDInd Recommended UDE
20 Employment status 

(Retired)

 		Status of participant/subject's current employment EmplmtStatus Recommended UDE
21 Return to work date  Date the participant returned to work following their injury ReturnToWorkDate Recommended UDE
22 Weeks employed number  Number of weeks employed in the last year WeeksEmployedNum Recommended UDE
23 Emploment hours per week number  Average number of hours per week usually worked in all paid competitive jobs in the month prior to evaluation EmplmtHrsWkNum Recommended UDE
24 Total salary category  Category of annualized income from all employment at the time of the evaluation TotalSalaryCat Recommended UDE
25 Currently employed indicator  Whether subject is currently employed EmployedInd Recommended UDE
26 Occupation type  Type of occupation in the month prior to follow-up OccupationTyp Recommended UDE
27 Family income category  Category of household income during the past year FamilyIncomeCat Recommended UDE
28 Motorized vehicle transportation type  Type of motorized vehicular transportation MotorizedVehTransportationTyp Recommended UDE
29 Seizure indicator  Indicator of seizure activity SeizInd Recommended CDE
30 Seizure number category  Category indicating number of seizures in the past year SeizNumCat Recommended UDE

Form II rehospitalization (Appears Up To 5 Times)

# Title Short Description Variable Name Required? Type
1 Rehospitalization indicator  Indicator of rehospitalization in the past year RehospInd Recommended UDE
2 Rehospitalization type  Type of rehospitalization in the past year RehospTyp Recommended UDE

Form II medical history (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Hypertension indicator  Indicator of hypertension. In adults, hypertension is defined as a systolic pressure >= 140 and a diastolic >= 90. In children, it is defined as systolic blood pressure >95th percentile for age HypertensInd Recommended CDE
2 Congestive Heart Failure (CHF) indicator  Complications Cardiovascular: CHF Indicator CHFInd Recommended UDE
3 Myocardial infarction indicator  Complications Cardiovascular: MI Indicator MIInd Recommended UDE
4 Other heart condition indicator  Indicator as to whether the participant/subject has or had a heart condition other than hypertension, CHF, or MI OthHeartCondInd Recommended UDE
5 Stroke indicator  Complications Neuro: Stroke Indicator StrokeInd Recommended UDE
6 Emphysema (COPD) indicator  Indicator of a emphysema (COPD) diagnosis. EmphysemaInd Recommended UDE
7 Behavioral Risk Factor Surveillance System (BRFSS) - Diabetes have had indicator  Indicator for being told of diabetes by health professional, as part of the Behavioral Risk Factor Surveillance System (BRFSS) BRFSSDiabetesInd Recommended UDE
8 Cancer history indicator  Indicator as to whether the participant/subject has or had cancer. CancerHistInd Recommended CDE
9 Liver disease indicator  Indicator as to whether the participant/subject has or had liver disease LiverDiseaseInd Recommended UDE

Form II general health (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 General health scale  Scale indicating the participant's general health - derived from Medicare Survey Question #1 GenHlthScl Recommended UDE
2 Physical health scale  Scale indicating the participant's physical health - derived from Medicare Survey Question #8 PhyHlthScl Recommended UDE
3 Days not in good physical health number  Number of days during the past 30 days that the participant's health was not good - derived from Medicare Survey Question #11 PhysHlthNum Recommended UDE
4 Emotional health scale  Scale indicating the participant's emotional health - derived fromMedicare Survey Question #9 EmotHlthScl Recommended UDE

Form II subject history (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Height measurement  Measurement of participant's/subject's height. HgtMeasr Recommended CDE
2 Weight measurement  Measurement of participant's/subject's weight WgtMeasr Recommended CDE
3 Cigarette use frequency  Frequency of cigarette use CigaretteUseFreq Recommended UDE
4 Tobacco use frequency  Frequency of tobacco (chewing tobacco, snuff, or snus) use TobcoUseFreq Recommended UDE
5 Illicit drug substance ever used indicator  Indicator ofillicit drug substance ever used IllicitDrgSubEverUseInd Recommended UDE
6 Alcohol prior use indicator  Indicator of the participant's/subject's alcohol consumption prior to the past 12 months AlcPriorUseInd Recommended CDE
7 Alcohol use days per week  Number of days per week that subject typically drinks alcohol AlchlUseDaysPerWeek Recommended UDE
8 Alcohol use last month days drank number  During the past 30 days, how many days per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor? AlcoholUseLastMoDayDrnkNum Recommended CDE
9 Alcohol use last month drinking day average drinks number  During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? NOTE: One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. AlchlUseLstMoDrnkDyAvgDrnksNum Recommended CDE
10 Alcohol use last month consumed more than four or five drinks days number  Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [X = 5 for men, X = 4 for women] or more drinks on an occasion? AlcohlLstMoConsmOvr5DrnkDayNum Recommended CDE
11 Criminal arrests indicator  Indicator of criminal arrests CrimArrestsInd Recommended UDE

Form II SRS Score (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Supervision rating scale (SRS) - Final score  Final score, as part of the Supervision Rating Scale (SRS) SRSFinalScore Recommended UDE
Keywords

Change History