Form Structure: Functional Independence Measure for Children (WeeFIM) : FITBIR : Federal Interagency Traumatic Brain Injury Research Informatics System

Form Structure: Functional Independence Measure for Children (WeeFIM)

This form structure is an organized set of data definitions for a copyrighted form

Resource:

FITBIR

Title:

Functional Independence Measure for Children (WeeFIM)

Short Name:

WeeFIM

Description:

The Functional Independence Measure for Children (WeeFIM) is an 18-item, seven-level ordinal scale instrument used to assess a child's typical and consistent performance.Children 0 to <3 years no WeeFIM (or FIM) is required. Children 3 to <12 years WeeFIM must be used because age norms apply. Children 12 to 18 years as no age norms apply, either the WeeFIM or FIM can be used. Copyright 2003 Uniform Data System for Medical Rehabilitation; Msall, M. E., DiGaudio, K., Duffy, L. C., LaForest, S., Braun, S., & Granger, C. V. (1994). WeeFIM. Normative sample of an instrument for tracking functional independence in children. Clin Pediatr (Phila), 33(7), 431-438. http://cpj.sagepub.com/content/33/7/431.full.pdf

Disease:

General (For all diseases) Traumatic Brain Injury

Organization:

NIH/CIT/BRICS

Required Program Form:

Standardization:

Standard NINDS CDE

Labels:

Form Type:

Clinical Assessment

Version:

1.0

Date Created:

2016-10-17

Owner:

Number of Data Elements:

eForms:

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

WeeFIM Instrument Motor Self Care Assesstment (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Wee FIM instrument for children Self-care subscale of Motor domain-Eating scale	Scaled ability of a subject to eat independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareEatingScl	Recommended	CDE
2	Wee FIM instrument for children Self-care subscale of Motor domain-Grooming scale	Scaled ability of a subject to groom independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareGroomingScl	Recommended	CDE
3	Wee FIM instrument for children Self-care subscale of Motor domain-Bathing scale	Scaled ability of a subject to bath independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareBathingScl	Recommended	CDE
4	Wee FIM instrument for children Self-care subscale of Motor domain-Dressing lower body scale	Scaled ability of a subject to dress lower body independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSlfCaDresLowBodScl	Recommended	CDE
5	Wee FIM instrument for children Self-care subscale of Motor domain-Dressing upper body scale	Scaled ability of a subject to dress upper body independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSlfCaDresUppBodyScl	Recommended	CDE
6	Wee FIM instrument for children Self-care subscale of Motor domain-Toileting scale	Scaled ability of a subject to toilet independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSlfCaToiletingScl	Recommended	CDE
7	Wee FIM instrument for children Self-care subscale of Motor domain-Bladder management scale	Scaled ability of a subject control/manage their bladder, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfBladderScl	Recommended	CDE
8	Wee FIM instrument for children Self-care subscale of Motor domain-Bowel management scale	Scaled ability of a subject control/manage their bowel, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareBowelScl	Recommended	CDE
9	Wee FIM instrument for children Self- care subscale of Motor domain-Total score	Self-care subscore of Motor domain, as part of the WeeFIM instrument for children	WeeFIMMotorSelfCareScore	Recommended	CDE

WeeFIM Instrument Motor Self Care Goal (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Wee FIM instrument for children Self-care subscale of Motor domain-Eating scale	Scaled ability of a subject to eat independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareEatingScl	Recommended	CDE
2	Wee FIM instrument for children Self-care subscale of Motor domain-Grooming scale	Scaled ability of a subject to groom independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareGroomingScl	Recommended	CDE
3	Wee FIM instrument for children Self-care subscale of Motor domain-Bathing scale	Scaled ability of a subject to bath independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareBathingScl	Recommended	CDE
4	Wee FIM instrument for children Self-care subscale of Motor domain-Dressing lower body scale	Scaled ability of a subject to dress lower body independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSlfCaDresLowBodScl	Recommended	CDE
5	Wee FIM instrument for children Self-care subscale of Motor domain-Dressing upper body scale	Scaled ability of a subject to dress upper body independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSlfCaDresUppBodyScl	Recommended	CDE
6	Wee FIM instrument for children Self-care subscale of Motor domain-Toileting scale	Scaled ability of a subject to toilet independently, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSlfCaToiletingScl	Recommended	CDE
7	Wee FIM instrument for children Self-care subscale of Motor domain-Bladder management scale	Scaled ability of a subject control/manage their bladder, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfBladderScl	Recommended	CDE
8	Wee FIM instrument for children Self-care subscale of Motor domain-Bowel management scale	Scaled ability of a subject control/manage their bowel, as part of the self-care subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorSelfCareBowelScl	Recommended	CDE

WeeFIM Instrument Motor Mobility Assessment (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Wee FIM instrument for children Mobility subscale of Motor domain-Chair wheelchair scale	Scaled ability of a subject control/manage their chair/wheelchair, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityChWCScl	Recommended	CDE
2	Wee FIM instrument for children Mobility subscale of Motor domain-Toilet scale	Scaled ability of a subject to transfer themselves to/from a toilet, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityToiletScl	Recommended	CDE
3	Wee FIM instrument for children Mobility subscale of Motor domain-Tub shower scale	Scaled ability of a subject to transfer themselves to/from a tub or shower, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityTubShowScl	Recommended	CDE
4	Wee FIM instrument for children Mobility subscale of Motor domain-Walk wheelchair scale	Scaled ability of a subject to walk or use a wheelchair, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityWlkWCScl	Recommended	CDE
5	Wee FIM instrument for children Mobility subcale of Motor domain-Walk wheelchair catergory	Category of mobility used by the subject (walk/wheelchair/crawl/combination), as part of the Motor subscale of the WeeFIM instrument for children	WeeFIMMotorMobilityWlkWCCat	Recommended	CDE
6	Wee FIM instrument for children Mobility subscale of Motor domain-Stairs scale	Scaled ability of a subject to use stairs, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityStairsScl	Recommended	CDE
7	Wee FIM instrument for children Mobility subscale-Score	Mobility subscore of Motor domain, as part of the WeeFIM instrument for children	WeeFIMMotorMobilityScore	Recommended	CDE

WeeFIM Instrument Motor Mobility Goal (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Wee FIM instrument for children Mobility subscale of Motor domain-Chair wheelchair scale	Scaled ability of a subject control/manage their chair/wheelchair, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityChWCScl	Recommended	CDE
2	Wee FIM instrument for children Mobility subscale of Motor domain-Toilet scale	Scaled ability of a subject to transfer themselves to/from a toilet, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityToiletScl	Recommended	CDE
3	Wee FIM instrument for children Mobility subscale of Motor domain-Tub shower scale	Scaled ability of a subject to transfer themselves to/from a tub or shower, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityTubShowScl	Recommended	CDE
4	Wee FIM instrument for children Mobility subscale of Motor domain-Walk wheelchair scale	Scaled ability of a subject to walk or use a wheelchair, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityWlkWCScl	Recommended	CDE
5	Wee FIM instrument for children Mobility subcale of Motor domain-Walk wheelchair catergory	Category of mobility used by the subject (walk/wheelchair/crawl/combination), as part of the Motor subscale of the WeeFIM instrument for children	WeeFIMMotorMobilityWlkWCCat	Recommended	CDE
6	Wee FIM instrument for children Mobility subscale of Motor domain-Stairs scale	Scaled ability of a subject to use stairs, as part of the mobility subscale of Motor domain of the WeeFIM instrument for children	WeeFIMMotorMobilityStairsScl	Recommended	CDE

WeeFIM Instrument Cognition Assessment (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	WeeFIM instrument for children Cognition subscale-Comprehension scale	Scaled ability of a subject to comprehend (auditory/visual/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognCompehensScl	Recommended	CDE
2	WeeFIM instrument for children Cognition subscale-Comprehension category	Category of usual mode of comprehension (auditory/visual/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognCompehensCat	Recommended	CDE
3	WeeFIM instrument Cognition subscale-Expression scale	Scaled ability of a subject to comprehend (vocal/nonvocal/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognExpressionScl	Recommended	CDE
4	WeeFIM instrument for children Cognition subscale-Expression category	Category of usual mode of comprehension (vocal/nonvocal/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognExpressionCat	Recommended	CDE
5	Wee FIM instrument for children Cognition subscale-Social interaction scale	Scaled ability of a subject to handle social interactions, as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognSocialInterScl	Recommended	CDE
6	Wee FIM instrument for children Cognition subscale-Problem solving scale	Scaled ability of a subject to handle problem solving, as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognProSolvScl	Recommended	CDE
7	WeeFIM instrument for children Cognition subscale-Memory scale	Scaled ability of a subject to memorize, as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognMemoryScl	Recommended	CDE

WeeFIM Instrument Cognition Goal (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	WeeFIM instrument for children Cognition subscale-Comprehension scale	Scaled ability of a subject to comprehend (auditory/visual/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognCompehensScl	Recommended	CDE
2	WeeFIM instrument for children Cognition subscale-Comprehension category	Category of usual mode of comprehension (auditory/visual/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognCompehensCat	Recommended	CDE
3	WeeFIM instrument Cognition subscale-Expression scale	Scaled ability of a subject to comprehend (vocal/nonvocal/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognExpressionScl	Recommended	CDE
4	WeeFIM instrument for children Cognition subscale-Expression category	Category of usual mode of comprehension (vocal/nonvocal/both), as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognExpressionCat	Recommended	CDE
5	Wee FIM instrument for children Cognition subscale-Social interaction scale	Scaled ability of a subject to handle social interactions, as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognSocialInterScl	Recommended	CDE
6	Wee FIM instrument for children Cognition subscale-Problem solving scale	Scaled ability of a subject to handle problem solving, as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognProSolvScl	Recommended	CDE
7	WeeFIM instrument for children Cognition subscale-Memory scale	Scaled ability of a subject to memorize, as part of Cognition subscale of the WeeFIM instrument for children	WeeFIMCognMemoryScl	Recommended	CDE

WeeFIM Instrument Score (Appears Up To 1 Time)

#	Title	Short Description	Variable Name	Required?	Type
1	Wee FIM instrument for children-Wee FIM Total Rating Score	Total score for the WeeFIM instrument for children	WeeFIMTotalScore	Recommended	CDE
2	Wee FIM instrument for children-Motor subscore	Motor functions subscore, as part of the Motor subscale of the WeeFIM instrument for children	WeeFIMMotorSubScore	Recommended	CDE
3	Wee FIM instrument for children-Cognition functions score	Cognition functions subscore, as part of the Cognition subscale of the WeeFIM instrument for children	WeeFIMCognFunctScore	Recommended	CDE

Keywords