This form structure is an organized set of data definitions for a form that has not been copyrighted

 General Details

Title:
Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C)
Short Name:
AUDITC
Description:
AUDIT-C is a 3-item alcohol screen that can help identify person who are hazardous drinkers or have active alcohol use disorders(including alcohol abuse or dependence). AUDIT-C is a modified version of the 10 question AUDIT instrument. Recommended by CDISC for TBI (TAUG TBI) Refferences: https://www.cdisc.org/foundational/qrs
Disease:
Traumatic Brain Injury
Organization:
CNRM/HJF
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2016-06-01
Version:
1.2
Date Created:
2016-02-02
Owner:
Number of Data Elements:
17
eForms:
N

 Documentation


 Groups & Attached Data Elements

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 (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

AUDITC (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Alcohol Use Disorders Identification Test (AUDIT) - Drink contain alcohol frequency score  Score for the frequency with which the subject consumes alcoholic drinks. AUDITDrnkContainAlcFreqScore Recommended CDE
2 Alcohol Use Disorders Identification Test (AUDIT) - Alcohol drink typical day number score  Score for the number of drinks the subject consumes on a day he or she is drinking. AUDITAlcDrnkTypclDayNumScore Recommended CDE
3 Alcohol Use Disorders Identification Test (AUDIT) - More than 6 alcohol drink frequency score  Score for the frequency with which the subject consumes six or more alcoholic drinks on a single occasion. AUDITMoreThan6AlcDrnkFreqScore Recommended CDE

AUDITC Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) - Total Score  The subject's AUDIT-C total score (0-12) AUDITCTotalScore Optional CDE

 Change History

 Administrative Change History