Form Structure: TBI-QOL Item Bank v1.0-Mobility-Short Form 10a
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
TBI-QOL Item Bank v1.0-Mobility-Short Form 10a
Short Name:
TBIQOLMobility
Description:
TBI-QOL Mobility is a 10 item short form that assesses an individual's ability to carry out various activities involving the trunk region and increasing degrees of bodily movement, ambulation, balance, or endurance. This instrument includes items from Neuro-QOL Adult Bank Lower Extremity Function. Tulsky, D. S., Kisala, P. A., Victorson, D., Carlozzi, N., Bushnik, T., Sherer, M., & Englander, J. (2016). TBI-QOL: development and calibration of item banks to measure patient reported outcomes following traumatic brain injury.The Journal of head trauma rehabilitation, 31(1), 40. TBI-QOL Items Copyright 2015 David Tulsky and Kessler Foundation. All rights reserved. http://www.assessmentcenter.net/ Recommended by CDISC for TBI
Disease:
Traumatic Brain Injury
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-06-02
Owner:
Number of Data Elements:
27
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 (Repeat Infinitely)
| # | 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 |
TBI-QOL Mobility (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Quality of Life - Movement armless straight chair stand up difficulty scale | The scale which represents the amount of difficulty the participant currently has in standing up from an armless straight chair (e.g., dining room chair), as part of Neuro-QOL Lower Extremity Function. | QoLMoveArmlssStrghtChrAbltyScl | Recommended | CDE |
| 2 | Quality of Life - Movement flight stair handrail up down difficulty scale | The scale which represents the amount of difficulty the participant currently has in going up and down a flight of stairs inside, using a handrail, as part of Neuro-QOL Lower Extremity Function. | QolMoveFlghtStrUpDwnDiffScl | Recommended | CDE |
| 3 | Quality of Life - Movement uneven surface walk difficulty scale | The scale which represents the amount of difficulty the participant currently has in walking on uneven surfaces (e.g., grass, dirt road or sidewalk), as part of Neuro-QOL Lower Extremity Function. | QolMoveUnevenSrfaceWlkDiffScl | Recommended | CDE |
| 4 | Quality of Life - Movement single floor walk difficulty scale | The scale which represents the amount of difficulty the participant currently has in walking around one floor of their home, as part of Neuro-QOL Lower Extremity Function. | QolMoveSingleFloorWalkDiffScl | Recommended | CDE |
| 5 | Quality of Life - Movement no handrail stair climb difficulty scale | The scale which represents the amount of difficulty the participant currently has in climbing stairs step over step without a handrail (alternating feet), as part of Neuro-QOL Lower Extremity Function. | QoLMoveNoHandrlStrClmbDiffScl | Recommended | CDE |
| 6 | TBI Quality of Life (TBI-QOL) - Difficulty walking in a busy place without losing balance scale | The scale representing how much difficulty the participant currently have walking in a busy place without losing their balance. | TBIQOLDiffcltyWalkngBsyPlceScl | Recommended | CDE |
| 7 | Quality of Life - Movement walk fifteen minute duration ability scale | The scale which represents the extent to which the participant was able to go for a walk of at least 15 minutes, as part of Neuro-QOL Lower Extremity Function. | QolMoveWlkFftnMinDurAbltyScl | Recommended | CDE |
| 8 | Quality of Life - Movement up down step curb ability scale | The scale which represents the extent to which the participant was able to step up and down curbs, as part of Neuro-QOL Lower Extremity Function. | QolMoveUpDownStepCurbAbltyScl | Recommended | CDE |
| 9 | Quality of Life - Movement in out car ability scale | The scale which represents the extent to which the participant was able to get in and out of the car, as part of Neuro-QOL Lower Extremity Function. | QolMoveInOutCarAbilityScl | Recommended | CDE |
TBI-QOL Mobility Scoring (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | TBI Quality of Life (TBI-QOL) - Mobility raw score | The raw score for TBI-QOL Mobility. | TBIQOLMobilityRawScore | Recommended | CDE |
| 2 | TBI Quality of Life (TBI-QOL) - Mobility T-score | The T-Score related to ability to carry out various activities involving the trunk region and increasing degrees of bodily movement, ambulation, balance, or endurance. | TBIQOLMobTScore | Recommended | CDE |
| 3 | TBI Quality of Life (TBI - QOL) - Standard error | Standard error (a statistical measure of variance that represents the margin of error for the T-score), as part of TBI-Quality of Life (TBI-QOL) measures | TBIQOLStandardError | Recommended | CDE |
Keywords
