Form Structure: TBI-QOL Item Bank v1.0 - Upper Extremity - Short Form 9a
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 - Upper Extremity - Short Form 9a
Short Name:
TBIQOLUpperExtremity
Description:
TBI-QOL Upper Extremity includes 9 items that assess the ability to carry out various activities involving digital, manual, and reach-related functions, ranging from fine motor to self-care (activities of daily living). This short form includes items from PROMIS Upper Extremity and Physical Function, and Neuro-QOL Upper Extremity. 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 Upper Extremity (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | TBI Quality of Life (TBI-QOL) -Difficulty applying spreads to bread using a knife scale | The scale representing how much difficulty the participant currently has applying spreads to bread using a knife | TBIQOLDiffcltyApplySpdBreadScl | Recommended | CDE |
| 2 | Quality of Life - Movement dress pullover shirt on difficulty scale | The scale which represents the amount of difficulty the participant currently has in putting on a pullover shirt, as part of Neuro-QOL Upper Extremity. | QolMoveDrssPllvrShrtAblityScl | Recommended | CDE |
| 3 | TBI- Quality of Life (TBI-QOL)- Difficulty putting band-aid or gauze pad scale | The scale which represents the amount of difficulty the participant currently has putting on a Band-Aid or gauze pad on his/her self. | TBIQOLDiffcltyBandAidScl | Recommended | CDE |
| 4 | TBI-Quality of Life (TBI-QOL) - Able to open can with a hand can opener scale | The scale which represents the participants ability to open a can with a hand can opener | TBIQOLAbleCanOpenScl | Recommended | CDE |
| 5 | Quality of Life - Movement zipper open close ability scale | The scale which represents the extent to which the participant was able to open and close a zipper, as part of Neuro-QOL Upper Extremity. | QoLMoveZipprOpnClseAblityScl | Recommended | CDE |
| 6 | Quality of Life - Movement pick up coin ability scale | The scale which represents the extent to which the participant was able to pick up coins from a table top, as part of Neuro-QOL Upper Extremity. | QoLMovePckUpCoinAbltyScl | Recommended | CDE |
| 7 | Quality of Life - Movement full food plate hold ability scale | The scale which represents the extent to which the participant was able to hold a plate full of food, as part of Neuro-QOL Upper Extremity. | QolMoveFulFoodPlatHldAbltyScl | Recommended | CDE |
| 8 | Quality of Life - Movement shampoo hair ability scale | The scale which represents the extent to which the participant was able to shampoo their hair, as part of Neuro-QOL Upper Extremity. | QoLMoveShampooHairAbilityScl | Recommended | CDE |
| 9 | Quality of Life - Movement fingernail trim ability scale | The scale which represents the extent to which the participant was able to trim their fingernails, as part of Neuro-QOL Upper Extremity. | QolMoveFingernlTrimAbiltyScl | Recommended | CDE |
TBI-QOL Upper Extremity Scoring (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | TBI- Quality of Life (TBI-QOL) Upper extremity raw score | The raw score for TBI-QOL Upper Extremity. | TBIQOLUEXRawScore | Recommended | CDE |
| 2 | TBI Quality of Life (TBI-QOL) - Upper extremity function T-score | The T-Score related to ability to carry out various activities involving digital, manual, and reach-related functions, ranging from fine motor to self-care (activities of daily living). | TBIQOLUEXTScore | 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
