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Form Structure: TBI-QOL Item Bank v1.0 - Pain Interference - 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 - Pain Interference - Short Form 10a
Short Name:
TBIQOLPainInterference
Description:
TBI-QOL Pain Interference is a 10-item short form that assesses the consequences of pain on relevant aspects of one’s life, including the extent to which pain hinders engagement with social, cognitive, emotional, physical, and recreational activities. This short form is comprised of items from PROMIS Pain Interference. 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
Organization:
NIH/CIT/BRICS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2016-12-08
Version:
1.1
Date Created:
2016-06-02
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 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

TBI-QOL Pain interference (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 TBI Quality of Life (TBI-QOL) - Feel emotionally tense because of your pain scale  The scale representing how often in the past 7 days the participant did feel emotionally tense because of their pain. TBIQOLEmotionallyTensePainScl Recommended CDE
2 TBI Quality of Life (TBI-QOL) -Pain interfere with your family life  The scale representing how often in the past 7 days pain interfered with participant's family life. TBIQOLPainInterfereFamilyScl Recommended CDE
3 TBI Quality of Life (TBI-QOL) - Pain interfere with doing your tasks away from home scale  The scale representing how much pain interfered with doing the participant's tasks away from home. TBIQOLPainInterfereTasksScl Recommended CDE
4 TBI Quality of Life (TBI-QOL) - Pain feel like a burden scale  The scale representing how much pain felt like a burden to the participant. TBIQOLPainFeelBurdenScl Recommended CDE
5 TBI Quality of Life (TBI-QOL) - Pain interfere with enjoyment of life scale  The scale representing how much pain interfered with the participant's enjoyment of life. TBIQOLPainInterferEnjoymentScl Recommended CDE
6 TBI Quality of Life (TBI-QOL) - Pain interfere with household chores scale  The scale representing how much pain interfered with participant's household chores. TBIQOLPainHouseholdChoresScl Recommended CDE
7 TBI Quality of Life (TBI-QOL) - Pain interfere with enjoyment of social activities scale  The scale representing how much pain interfered with participant's enjoyment of social activities. TBIQOLPainSocialActivitiesScl Recommended CDE
8 TBI Quality of Life (TBI-QOL) - Pain interfere with ability to remember things scale  The scale representing how much in the past 7 days pain interfered with participant's ability to remember things TBIQOLPainAbilityRememberScl Recommended CDE
9 TBI Quality of Life (TBI-QOL) - Pain interfere with ability to concentrate scale  The scale representing how much in the past 7 days pain interfered with the participant's ability to concentrate. TBIQOLPainConcentrateScl Recommended CDE
10 TBI Quality of Life (TBI-QOL) - Pain keep from socializing with others scale  The scale representing how often in the past 7 days pain kept participant from socializing with others. TBIQOLPainSocializingScl Recommended CDE

TBI-QOL Pain Interference Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 TBI Quality of Life (TBI-QOL) - Pain interference raw score  The raw score for pain interference. TBIQOLPainIntrferenceRawScore Recommended CDE
2 TBI Quality of Life (TBI-QOL) - Pain interference T-score  The T-Score related to consequences of pain on relevant aspects of one's life, including the extent to which pain hinders engagement with social, cognitive, emotional, physical, and recreational activities, as part of the TBI Quality of Life (TBI-QOL). TBIQOLPainIntTScore 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

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