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

 General Details

Title:
FITBIR Demographics Form
Short Name:
DemogrFITBIR
Description:
FITBIR Demographics standard form
Disease:
Traumatic Brain Injury
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-04-17
Version:
1.1
Date Created:
2015-01-22
Owner:
Number of Data Elements:
137
eForms:
Y

 Documentation


 Groups & Attached Data Elements

Logically grouped data elements with defined frequency at which they repeat.

There are no data elements in the main group.

Additional Element Groups

Listed below are your additional element groups.

Main Group (Appears Exactly 1 Time)

# 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 Required CDE
4 Visit date  Actual interview or visit date VisitDate Recommended CDE
5 Site name  The name of the site for the study SiteName Recommended CDE
6 Days since baseline  The number of days since baseline DaysSinceBaseline Optional CDE
7 Case control indicator  Indicator of whether subject is in the case or control arm of the study CaseContrlInd Optional CDE
8 General notes text  General notes GeneralNotesTxt Optional CDE

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

Subject Demographics (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Birth date  Date (and time, if applicable and known) the participant/subject was born BirthDate Optional CDE
2 Gender Type  Self-reported gender of the participant/subject. Gender is the socially constructed identity of sex. GenderTyp Recommended CDE
3 Sex participant or subject genotype type  Sex chromosomes of the participant/subject based upon genotyping SexSubjectGenotypTyp Recommended CDE
4 Sex participant or subject genotype other text  The free-text field related to Sex participant or subject genotype type specifying other text. Sex chromosomes of the participant/subject based upon genotyping SexSubjectGenotypOTH Recommended CDE
5 Hand preference type  Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusively. HandPrefTyp Recommended CDE
6 Race USA category  The subject self declared racial origination, independent of ethnic origination, using OMB approved categories. RaceUSACat Recommended CDE
7 Race category  Category of race(s) or region(s) the participant/subject most closely identifies with RaceCat Recommended CDE
8 Ethnicity USA category  Category of ethnicity the participant/subject most closely identifies with EthnUSACat Recommended CDE
9 Ethnicity category  The free-text field describing the category of ethnicity the participant/subject most closely identifies with. EthnCatTxt Recommended CDE

Subject Country of Birth and Current Residency (Appears Up To 5 Times)

# Title Short Description Variable Name Required? Type
1 Birth country ISO code  Code (ISO 3166-1 alpha-2 code) for country where the participant/subject was born BirthCntryISOCode Recommended CDE
2 Birth country name  Name for country where the participant/subject was born BirthCntryName Recommended CDE
3 Country of residence ISO code  Code (ISO 3166-1 alpha-2) for the country where the participant/subject currently lives. CntryResdnceISOCode Recommended CDE
4 Country of residence name  Name of the country where the participant/subject currently lives. CntryResdnceName Recommended CDE

Subject Language (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Language primary ISO code  Code (ISO 639-2 alpha-3 code) for the language the participant/subject speaks most often. LangPrimryTxt Recommended CDE
2 Language primary other text  The free-text field related to Language primary text specifying other text. Text for the language the participant/subject speaks most often LangPrimryOTH Recommended CDE
3 Language spoken fluent code  Code (ISO 639-2)for each language that the participant/subject speaks fluently LangSpokeFluentISOCode Recommended CDE
4 Language spoken Fluent text  Text for each language that the participant/subject speaks fluently LangSpokeFluentTxt Recommended CDE
5 Language written fluent ISO code  Code (ISO 639-2) for each language that the participant/subject writes fluently LandWrtnFlntlyISOCode Recommended CDE
6 Language written fluent text  Text for each language that the participant/subject writes fluently LangWrtnFlntlyTxt Recommended CDE

Subject Marital Status (Appears Up To 5 Times)

# Title Short Description Variable Name Required? Type
1 Marital or partner status  Status of participant/subjects current domestic relationship, whether marital or partnered MartlPartnerStatus Recommended CDE
2 Marital or partner status other text  The free-text field related to Marital or partner status specifying other text. Status of participant/subjects current domestic relationships. MartlPartnerStatusOTH Recommended CDE

Subject Living Situation (Appears Up To 5 Times)

# Title Short Description Variable Name Required? Type
1 Living situation of an adult subject  Living situation of an adult subject, including the primary person living with adult subject information SesPrimAdult Recommended CDE
2 Other primary person living with adult patient  Other Primary person living with adult patient SesPrimAdultOther Recommended CDE
3 Living situation of juvenile patient  Living situation of juvenile patient SesPrimChild Recommended CDE
4 Living situation of juvenile patient other text  Living situation of juvenile patient other text SesPrimChildOTH Recommended CDE
5 Living situation before injury type  Living situation of the participant/subject before injury. LivingSituationPreInjTyp Recommended CDE
6 Living situation before injury type, specifying other text  The free-text related to "LivingSituationPreInjTyp" specifying other text. LivingSituationPreInjTypOTH Recommended CDE
7 Subject cohabitants count  Count of other people with whom the participant/subject currently lives, cohabits, or stays SubjectCohabitCt Recommended CDE
8 Dependent children living in household number  Number of dependent children living in household DpndntChildLvngHshldNum Recommended CDE
9 Number of dependent children  Number of dependent children for a participant/subject DependentChildNum Recommended CDE
10 Residence area type  Type describing the participant's/subjects current location of residence ResidenceAreaTyp Recommended CDE
11 Residence type  Type of residence where the participant/subject is currently living ResdncTyp Recommended CDE
12 Residence other text  The free-text field related to Residence type specifying other text. Type of residence where the participant/subject is currently living ResdncOTH Recommended CDE

Subject Family Income (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Family income range  Range, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member FmlyIncRange Recommended CDE
2 Family income supported persons count  Count of all people, including the participant/subject, who are supported by the household gross annual income reported FamilyIncmeSupprtPersCt Recommended CDE
3 Family income value  Value, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member FamilyIncmeVal Recommended CDE
4 Household wage earners number  Number of wage earners in household HshldWgeEarnNum Recommended CDE
5 Income basic needs status  The status of how the household currently manages to meet basic needs as defined by food, shelter and clothing. IncomeBasicNeedsStatus Recommended CDE

Subject Education (Appears Up To 3 Times)

# Title Short Description Variable Name Required? Type
1 Education level USA type  Highest grade or level of school participant/subject has completed or the highest degree received EduLvlUSATyp Recommended CDE
2 Education level USA type other text  The free-text field related to Education level USA type, specifying other text. The highest level of education the participant/subject received. EduLvlUSATypOTH Recommended CDE
3 Education type  The type of education the participant/subject received. EduTyp Recommended CDE
4 Education other text  The free-text field related to Education type specifying other text. The type of education the participant/subject received. EduOTH Recommended CDE
5 Education year count  Number of years of education completed (age 5 and beyond) EduYrCt Recommended CDE
6 Highest level education pre-injury  Highest level education pre-injury HighestLvlEduPreInj Recommended CDE
7 Education school participation status  Status of participant/subjects current attendance at school EduSchoolParticipStatus Recommended CDE
8 School placement type  The description of the type of education the participant/subject receives with details of being with or without assistance. SchoolPlacementTyp Recommended CDE
9 School placement other text  The free-text field related to School placement type specifying other text. The description of the type of education the participant/subject receives with details of being with or without assistance. SchoolPlacementOTH Recommended CDE

Subject Occupation and Employment (Appears Up To 10 Times)

# Title Short Description Variable Name Required? Type
1 Occupation primary status  The status indicating the participant's/subjects current primary occupational status. OccupationPrimaryStatus Recommended CDE
2 Occupation primary status other text  The free-text field to capture other status indicating the participant's/subjects current primary occupational status. OccupationPrimaryStatusOTH Recommended CDE
3 Employment expanded status  Status of participant/subjects current employment EmplmtExpndStatus Recommended CDE
4 Employment expanded other text  The free-text field related to Employment expanded status specifying other text. Status of participant/subjects current employment EmplmtExpndOTH Recommended CDE
5 Job classification pre-injury  Job classification pre-injury JobClassPreInj Recommended CDE
6 Job classification pre-injury other text  The free-text field related to Job classification pre-injury specifying other text. JobClassPreInjOTH Recommended CDE
7 Job classification-now  Job classification-now JobClassNow Recommended CDE
8 Job classification-now other text  The free-text field related to Job classification-now specifying other text. JobClassNowOTH Recommended CDE
9 Unemployed reason  Participant/subject reason for unemployment UnemplymntRsn Recommended CDE

Parent Guardian or Caregiver Information (Appears Up To 6 Times)

# Title Short Description Variable Name Required? Type
1 Primary caregiver extended type  Type of relationship between the person who acts as the primary caregiver for the participant/subject and the participant/subject CaregvPrimryExtendType Recommended CDE
2 Primary caregiver extended type other text  The free-text field related to Primary caregiver extended type. CaregvPrimryExtendOTH Recommended CDE
3 Alive status of subjects parents  Specifies whether the participant's/subjects parents are still living ParentAliveStatus Recommended CDE
4 Gender Type  Self-reported gender of the participant/subject. Gender is the socially constructed identity of sex. GenderTyp Recommended CDE
5 Race USA category  The subject self declared racial origination, independent of ethnic origination, using OMB approved categories. RaceUSACat Recommended CDE
6 Race category  Category of race(s) or region(s) the participant/subject most closely identifies with RaceCat Recommended CDE
7 Ethnicity USA category  Category of ethnicity the participant/subject most closely identifies with EthnUSACat Recommended CDE
8 Ethnicity category  The free-text field describing the category of ethnicity the participant/subject most closely identifies with. EthnCatTxt Recommended CDE
9 Birth country ISO code  Code (ISO 3166-1 alpha-2 code) for country where the participant/subject was born BirthCntryISOCode Recommended CDE
10 Birth country name  Name for country where the participant/subject was born BirthCntryName Recommended CDE
11 Marital or partner status  Status of participant/subjects current domestic relationship, whether marital or partnered MartlPartnerStatus Recommended CDE
12 Dependent children living in household number  Number of dependent children living in household DpndntChildLvngHshldNum Recommended CDE
13 Number of dependent children  Number of dependent children for a participant/subject DependentChildNum Recommended CDE
14 Residence area type  Type describing the participant's/subjects current location of residence ResidenceAreaTyp Recommended CDE
15 Residence type  Type of residence where the participant/subject is currently living ResdncTyp Recommended CDE
16 Residence other text  The free-text field related to Residence type specifying other text. Type of residence where the participant/subject is currently living ResdncOTH Recommended CDE
17 Education level primary caregiver USA type  Highest grade or level of school the participant's/subjects primary caregiver has completed or the highest degree he/she has received EduLvlPrimCaregiverUSATyp Recommended CDE
18 Education primary caregiver year count  Number of years of education of the primary caregiver (age 5 and beyond). EduPrimCaregiverYrCt Recommended CDE
19 Occupation primary status  The status indicating the participant's/subjects current primary occupational status. OccupationPrimaryStatus Recommended CDE
20 Occupation primary status other text  The free-text field to capture other status indicating the participant's/subjects current primary occupational status. OccupationPrimaryStatusOTH Recommended CDE
21 Job classification category  Category that classifies work performed by participant/subject. JobclassCat Recommended CDE
22 Employment expanded status  Status of participant/subjects current employment EmplmtExpndStatus Recommended CDE
23 Employment expanded other text  The free-text field related to Employment expanded status specifying other text. Status of participant/subjects current employment EmplmtExpndOTH Recommended CDE
24 Unemployed reason  Participant/subject reason for unemployment UnemplymntRsn Recommended CDE
25 Family income range  Range, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member FmlyIncRange Recommended CDE
26 Family income value  Value, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member FamilyIncmeVal Recommended CDE
27 Family income supported persons count  Count of all people, including the participant/subject, who are supported by the household gross annual income reported FamilyIncmeSupprtPersCt Recommended CDE

Subject Military Status (Appears Up To 3 Times)

# Title Short Description Variable Name Required? Type
1 Active military status indicator  Whether participant currently has active military status MilActiveInd Recommended CDE
2 Military occupational status of participant  Military occupational status of participant MilMOS Optional CDE
3 Military occupational status of participant other text  Military occupational status of participant other text MilMOSOTH Optional CDE
4 Military USA service branch type  Branch of service in the U.S. military, not including the Commissioned Corps MilUSAServBrnchTyp Optional CDE
5 Military USA service branch other text  The free-text field related to Military USA service branch type specifying other text. Branch of service in the U.S. military, not including the Commissioned Corps MilUSAServBrnchOTH Optional CDE
6 Military rank category  Category that describes the participant's/subjects rank in the military MilRnkCat Optional CDE
7 Military rank category other text  The free-text field related to Military rank category specifying other text. Category that describes the participant's/subjects rank in the military MilRnkCatOTH Optional CDE
8 To where the military patient was deployed  Region or country the military patient was deployed MilDeploy Optional CDE
9 To where the military patient was deployed other text  Region or country to where the military patient was deployed other text MilDeployOTH Optional CDE

Subject Involvement in Sports (Appears Up To 10 Times)

# Title Short Description Variable Name Required? Type
1 Injury from sports indicator  TBI Screen: Injured head/neck doing sports TBISportInd Optional CDE
2 Sport(s) participation in elementary school indicator  Whether subject participated in sport(s) in elementary school ElementarySchoolSprtInd Optional CDE
3 Primary elementary school sport played  The primary sport the participant played in elementary school ElementarySchoolPrimaryPlayed Optional CDE
4 Years played sports elementary school number  Number of years subject played sport(s) in elementary school ElementarPrimarySprtYrsNum Optional CDE
5 Other sports subject played in elementary school  Which other sports the participant played in elementary school ElementarySchoolSportOthrPlayd Optional CDE
6 Total combined years the participant played other elementary school sport(s)  Total combined number of years the participant played other sport(s) in elementary school ElementarySchoolSportOtherYrs Optional CDE
7 Sport(s) participation in junior high school indicator  Whether subject played sports in junior high school JuniorHighSchoolSportInd Optional CDE
8 Primary sport subject played in junior high school  Which sports subject played in junior high school JuniorHighPrimarySportPlayed Optional CDE
9 Years played sports junior high school number  Number of years subject played sport(s) in junior high school JuniorHighPrimarySprtYrsNum Optional CDE
10 Other sports subject played in Junior high school  Which sports subject played inJunior high school JuniorHighSportOtherplayed Optional CDE
11 Total combined years the participant played other junior high school sport(s)  Total combined number of years subject played sport(s) junior high school JuniorHighSportOtherYrs Optional CDE
12 Sport(s) participation in high school indicator  Whether subject played sports in high school HighSchoolSportInd Optional CDE
13 Primary high school sport played  The primary sport the participant played in high school HighSchoolSportPrimaryplayed Optional CDE
14 Years played primary high school sport number  Number of years subject played sport(s) in high school HighSchoolPrimarySportYears Optional CDE
15 Other sports subject played in high school  Which sports subject played in high school HighSchoolSportOtherplayed Optional CDE
16 Total combined years the participant played other high school sport(s)  Total combined number of years participant played other sport(s) in high school HighSchoolSportOtherYears Optional CDE
17 Sport(s) participation in college indicator  Indicator whether the participant played sports in college. CollegeSportInd Optional CDE
18 Primary college sport played by the participant  The primary sport the participant played in college. CollegeSportPrimaryPlayed Optional CDE
19 Total combined years the partisipant played primary college sport  Total combined years the partisipant played primary college sport. CollegeSportPrimaryYears Optional CDE
20 Other sport(s) the participant played in college  Other sports the participant played in college. A complimentary UDE for "Primary college sport played by the participant". CollegeSportPlayedOTH Optional CDE
21 College sport other played  College sports played other than primary sport CollegeSportOtherPlayed Optional CDE
22 Total combined years the partisipant played other college sport(s)  Total combined years the partisipant played other college sport(s). CollegeSportOtherYears Optional CDE
23 Recreational sport(s) participation indicator  Whether the participant played recreational sports RecreationallSportInd Optional CDE
24 Primary recreational sport played by the participant  Which sport the participant primarily played recreationally RecreationaSportPrimaryPlayed Optional CDE
25 Total combined years the participant played primary recreational sport  Total number of years the participant played primary sport recreationally RecreationaSportPrimaryYears Optional CDE
26 Other recreational sports played by the participant  Which other sport(s) the participant played recreationally RecreationaSportOtherPlayed Optional CDE
27 Total combined years the participant played other recreational sport(s)  Total number of years subject played other sport(s) recreationally RecreationaSportOtherYears Optional CDE
28 Professional sport(s) participation indicator  Indicator whether the participant played sports professionally. ProfessionalSportInd Optional CDE
29 Primary professional sport played by the participant  The primary sport the participant played in college. ProfessionalSportPrimaryPlayed Optional CDE
30 Total combined years the partisipant played primary professional sport  Total combined years the participant played primary professional sport (should be used in combination with Primary professional sport played by the participant UDE). ProfessionalSportPrimaryYears Optional CDE
31 Other professional sports played by the participant  Other sports the participant played professionally. A complimentary UDE for Primary professional sport played by the participant. ProfessionalSportPlayedOTH Optional CDE
32 Professional sport other played  Professional sports played othre than primary sport ProfessionalSportOtherPlayed Optional CDE
33 Total combined years the partisipant played other professional sport(s)  Total combined years the participant played other professional sport(s) (should be used in combination with Other professional sports played by the participant. ProfessionalSportOtherYears Optional CDE

 Change History

 Administrative Change History