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

 General Details

Title:
Craig Handicap and Assessment Reporting Technique (CHART-SF)
Short Name:
CHARTSF
Description:
Craig Handicap and Assessment Reporting Technique paper and Interview forms (CHART-SF) provide a simple, objective measure of the degree to which impairments and disabilities result in handicaps in the years after initial rehabilitation. Six subscales: physical independence; cognitive independence; mobility; occupation; social integration; economic self-sufficiency.This form structure was built based on CDISC terminology. Recommended by CDISC for TBI (TAUG TBI)
Disease:
Traumatic Brain Injury
Organization:
NIH
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2014-08-25
Owner:
Number of Data Elements:
42
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 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

Form Completion (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Paid physical assistance hour value  Number of paid physical assistance hours the subject receives in a typical day, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFPaidPhysAssstncHrVal Recommended CDE
2 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Unpaid physical assistance hour value  Number of unpaid physical assistance hours the subjects needs in a typical day, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFUnpdPhysAssstncHrVal Recommended CDE
3 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Home activities assistance indicator  Indicator of assistance the subject receives in the subject's home with activities, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFHmActAssstncInd Recommended CDE
4 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Outside activities assistance indicator  Indicator of assistance the subject receives outside of the subject's home with activities, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFOutsdActAssstncInd Recommended CDE
5 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Off bed day hour value  Number of hours the subject spends out of bed on a typical day, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFOffBdDyHrVal Recommended CDE
6 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Outside week day value  Number of days the subject spends out of the house and go somewhere, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFOutsdWkDyVal Recommended CDE
7 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Outside year night indicator  Indicator of how many days the subject spent away from home, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFOutsdYrNgtInd Recommended CDE
8 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Paid job week hour value  Number of hours the subject spends working in a paid job per week, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFPaidJbWkHrVal Recommended CDE
9 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Paid job occupation text  Text of paid occupation the subject has, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFPaidJbOccptnTxt Recommended CDE
10 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Academic program week hour value  Number of hours the subject spends in school for a degree or other technical training program per week, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFAcadmcProgrmWkHrVal Recommended CDE
11 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Home making week hour value  Number of hours the subject spends for home making activities per week, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFHmMkngHrVal Recommended CDE
12 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Home improvement week hour value  Number of hours the subject spends for home maintenance activities per week, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFHmImprvmntWkHrVal Recommended CDE
13 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Recreational activities week hour value  Number of hours the subject spends for recreational activities per week, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFRecrtnlActWkHrVal Recommended CDE
14 Craig Handicap and Assessment Reporting Technique (CHART-SF) - People living with subject value  Number of people the subject lives with, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFPplLvngSubVal Recommended CDE
15 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Spouse significant other indicator  Indicator of if the subject lives with spouse or significant other, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFSpseSignfcntOthrInd Recommended CDE
16 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Living with relatives value  Number of relatives the subject lives with, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFLvngWthReltvVal Recommended CDE
17 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Business associate visit month value  Number of business or organizational associates the subject visits per month, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFBusnssAssctVstMoVal Recommended CDE
18 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Friends visit month value  Number of friends the subject visits per month, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFFrndVstMoVal Recommended CDE
19 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Strangers conversation month indicator  Indicator of how often the subject spoke to strangers in the last month, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFStrngrConvstnMoInd Recommended CDE
20 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Combined family income indicator  Indicator of subject and the subject's family combined income in the last year, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFCombndFmlyIncInd Recommended CDE
21 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Unreimbursed medical care expenses indicator  Indicator of how much money the subject spent for medical care expenses last year and did not get reimbursed for, as part of the Craig Handicap and Assessment Reporting Technique (CHART-SF) CHARTSFReimbrsdMedCrExpnsInd Recommended CDE

Scores (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Mobility Score  Total mobility score (0-100) CHARTSFMobilityScore Recommended CDE
2 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Physical Independence Score  Total physical independence score (0-100) CHARTSFPhysIndependScore Recommended CDE
3 Craig Handicap and Assessment Reporting Technique (CHART-SF) - Cognitive Independence Score  Total cognitive independence score (0-100) CHARTSFCogIndependScore Recommended CDE
4 Craig Handicap and Assessment Reporting Technique (CHART-SF) -Occupation Score  Total occupation score (0-100) CHARTSFOccupScore Recommended CDE
5 Craig Handicap and Assessment Reporting Technique (CHART-SF) -Economic Self Sufficiency Score  Total economic self-sufficiency score (0-100) CHARTSFEconSelfSufficScore Recommended CDE
6 Craig Handicap and Assessment Reporting Technique (CHART-SF) -Social Integration Score  Total social integration score (0-100) CHARTSFSocialIntgratnScore Recommended CDE

 Change History

 Administrative Change History