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

 General Details

Title:
Death Report
Short Name:
Death_Report
Description:
The Death Report CRF Module should only be completed in the event of the participant's/subject's death while enrolled in the study. It captures the date, time and the medical reason death is attributed.Based on NINDS F0388_Deat from.
Disease:
Traumatic Brain Injury , General (For all diseases)
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2014-04-09
Owner:
Number of Data Elements:
25
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 Recommended 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

Death report (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Death date and time  Date (and time, if known) of participant's/subject's death DeathDateTime Optional CDE
2 Injury elapsed time  The elapsed time (in minutes) from the time of injury InjElapsedTime Recommended CDE
3 Death cause ICD-10-CM code  ICD-10-CM code that describes the cause of participant/subject's death DeathCauseICD10CMCode Recommended CDE
4 Death cause text  Text describing the primary reason or cause of the participant/subject's death. If possible, this should be the explanation of the cessation of life according to the Death Certificate. DeathCauseTxt Optional CDE
5 Death location type  Type of location where the participant/subject died DeathLoctnTyp Recommended CDE
6 Death location other text  The free-text field related to 'Death location type' specifying other text. Type of location where the participant/subject died DeathLoctnOTH Recommended CDE
7 Diagnosis final clinical death date  Date of participant's/subject's final clinical diagnosis DiagnosFinalClinDeathDate Optional CDE
8 Diagnosis final clinical death type  Physician's final clinical diagnosis for the participant/subject DiagnosFinalClinDeathTyp Recommended CDE
9 Diagnosis final clinical death other text  The free-text field related to 'Diagnosis final clinical death type' specifying other text. Physician's final clinical diagnosis for the participant/subject DiagnosFinalClinDeathOTH Recommended CDE
10 Clinical event or milestone type  Type of clinical event or milestone pertinent to the disease or disorder ClinEvntMilestoneTyp Optional CDE

 Change History

 Administrative Change History