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

 General Details

Title:
Galveston Orientation and Amnesia Test (GOAT)
Short Name:
GOAT_FITBIR
Description:
The GOAT can be administered to assess the duration of post-traumatic amnesia, including ten items on recovery of orientation to person, place, and time. The duration of retrograde and anterograde amnesia can be assessed. It is appropriate for ages 16 and older. Recommended by CDISC for TBI (TAUG TBI)
Disease:
Traumatic Brain Injury
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-04-19
Version:
1.2
Date Created:
2015-03-12
Owner:
Number of Data Elements:
30
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 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

Additional Element Groups

Listed below are your additional element groups.

Form Administration Group (Repeat Infinitely)

# 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

Galveston Orientation & Amnesia Test (GOAT) (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 The Galveston Orientation and Amnesia Test (GOAT) - Full name score  Scored ability to accurately state first and last name, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATNameScore Recommended CDE
2 The Galveston Orientation and Amnesia Test (GOAT) - Born date score  Scored ability to accurately state date of birth, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATBrnDateScore Recommended CDE
3 The Galveston Orientation and Amnesia Test (GOAT) - Live location score  Scored ability to accurately state place of residence, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATLiveLocScore Recommended CDE
4 The Galveston Orientation and Amnesia Test (GOAT) - City location score  Scored ability to accurately name the city the subject is currently located, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATCityLocScore Recommended CDE
5 The Galveston Orientation and Amnesia Test (GOAT) - Building location score  Scored ability to accurately identify the building they are currently located, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATBuildingLocScore Recommended CDE
6 The Galveston Orientation and Amnesia Test (GOAT) - Hospital admittance date score  Scored ability to accurately identify hospital admittance date, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATHospAdmtDateScore Recommended CDE
7 The Galveston Orientation and Amnesia Test (GOAT) - Mode of transportation score  Scored ability to accurately identify the mode of transportation to the hospital, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATModeTranspScore Recommended CDE
8 The Galveston Orientation and Amnesia Test (GOAT) - Post injury event score  Scored ability to provide specific details about the first event after injury, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATFirstEvntScore Recommended CDE
9 The Galveston Orientation and Amnesia Test (GOAT) - Post injury event detail score  Scored ability to identify the detail of the first event the subject can remember after the accident, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATDetailScore Recommended CDE
10 The Galveston Orientation and Amnesia Test (GOAT) - Pre injury event score  Scored ability to accurately recall the last event before injury, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATLastEvntScore Recommended CDE
11 The Galveston Orientation and Amnesia Test (GOAT) - Pre injury event detail score  Scored ability to provide specific details about the last event before injury, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATPreInjuEventDetailScore Recommended CDE
12 The Galveston Orientation and Amnesia Test (GOAT) - Time score  Scored ability to identify the current time, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATCrntTimeScore Recommended CDE
13 The Galveston Orientation and Amnesia Test (GOAT) - Day week score  Scored ability to identify the current day of the week, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATDayScore Recommended CDE
14 The Galveston Orientation and Amnesia Test (GOAT) - Day month score  Scored ability to identify the current day of the month, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATDayMnthDateScore Recommended CDE
15 The Galveston Orientation and Amnesia Test (GOAT) - Month score  Scored ability to identify the current month, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATMnthScore Recommended CDE
16 The Galveston Orientation and Amnesia Test (GOAT) - Year identification score  Scored ability to identify the current year, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATYearScore Recommended CDE
17 The Galveston Orientation and Amnesia Test (GOAT) - Error sum value  Galveston Orientation and Amnesia Test (GOAT) sum of errors value GOATErrorSumVal Recommended CDE
18 The Galveston Orientation and Amnesia Test (GOAT) - Total score  Total score, as part of the Galveston Orientation and Amnesia Test (GOAT). GOATTotalScore Recommended CDE

 Change History

 Administrative Change History