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

 General Details

Title:
NIH ToolBox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form Ages 3-7
Short Name:
NIHTBFearSprtAnxPrtRpt3to7
Description:
This is a parent-report measure for ages 3-7, assessing fear of being separated from home and from loved ones. It is a 7-item fixed-length form. Copyright 2012 Northwestern University and the National Institutes of Health. http://www.nihtoolbox.org/Pages/NIH-Toolbox-Terms-and-Conditions.aspx
Disease:
General (For all diseases)
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-06-23
Owner:
Number of Data Elements:
37
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

NIH Toolbox Admiinistration (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox - Test domain battery type  Type of domain battery for the NIH Toolbox test being administered, as a part of the NIH Toolbox NIHTBTestDomainBatteryTyp Recommended CDE
2 NIH Toolbox - Test domain battery type other  The free-text related to NIHTBTestDomainBatteryTyp specifying other text, as part of the NIH Toolbox NIHTBTestDomainBatteryTypOTH Recommended CDE
3 NIH Toolbox - Test name type  Type of NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestNameTyp Recommended CDE
4 NIH Toolbox - Test name type other  The free-text related to NIHTBAdminTestNameTyp specifying other text, as part of the NIH Toolbox NIHTBAdminTestNameTypOTH Recommended CDE
5 NIH Toolbox - Test administration language type  Type of language for test being administrated, as part of the NIH Toolbox NIHTBTestAdminLanguageTyp Recommended CDE
6 NIH Toolbox - Test administration language type other  Free-text related to NIHTBTestAdminLanguageTyp specifying other text, as part of the NIH Toolbox NIHTBTestAdminLanguageTypOTH Recommended CDE
7 NIH Toolbox - Form administered type  Type of NIH Toolbox form being administered, as part of the NIH Toolbox NIHTBFormAdminTyp Recommended CDE
8 NIH Toolbox - Test administration flag indicator  Indicator of a flag for the NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestFlagInd Recommended CDE
9 NIH Toolbox - Test administration flag type  Type of flag for the NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestFlagTyp Recommended CDE

NIH Toolbox Fear Separation Anxiety Parent Rpt Ages 3-7 (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Worries about people scale  Scale of parent reported truth of statement: Worries that something bad will happen to people he/she is close to, for agesfor ages 3 to 7 of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7WrsAbtPplScl Recommended CDE
2 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Worries about being separated scale  Scale of parent reported truth of statement: Worries about being separated from loved ones, for agesfor ages 3 to 7 of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7WrsAbtSptdScl Recommended CDE
3 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Avoids school scale  Scale of parent reported truth of statement: Avoids school to stay home, for agesfor ages 3 to 7 of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7AvdsSchoolScl Recommended CDE
4 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Abandoned scale  Scale of parent reported truth of statement: Has nightmares about being abandoned, for agesfor ages 3 to 7 of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7AbndScl Recommended CDE
5 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Sick scale  Scale of parent reported truth of statement: Complains about feeling sick before separating from those who she/he is close to, for childrenfor ages 3 to 7 as a part of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7SickScl Recommended CDE
6 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Leaving scale  Scale of parent reported truth of statement: Is overly upset when leaving someone he/she is close to, for agesfor ages 3 to 7 of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7LeavingScl Recommended CDE
7 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Away scale  Scale of parent reported truth of statement: Is afraid of being away from home, for agesfor ages 3 to 7 of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7AwayScl Recommended CDE

NIH Toolbox Fear Separation Anxiety Prt Rpt 3-7 Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Raw Score  Raw score, as a part of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7RawScore Recommended CDE
2 NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form 3 to 7 - Theta score  Theta score, as a part of the NIH Toolbox Emotion Domain Fear Separation Anxiety Parent Report Fixed Form NIHTBFSAPRSF3to7ThetaScore Recommended CDE
3 NIH Toolbox Patient Reported Outcome (PRO) Measures - Age-adjusted scale score  Age-adjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures NIHTBPROAgeAdjSclScore Recommended CDE
4 NIH Toolbox Patient Reported Outcome (PRO) Measures - Age-adjusted national percentile value  Value of age-adjusted national percentile, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures NIHTBPROAgeAdjNationalPctVal Recommended CDE
5 NIH Toolbox Patient Reported Outcome (PRO) Measures - Fully-adjusted scale score  Fully-adjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures NIHTBPROFullyAdjSclScore Recommended CDE
6 NIH Toolbox Patient Reported Outcome (PRO) Measures - Unadjusted scale score  Unadjusted scale score, as part of the NIH Toolbox Patient Reported Outcome (PRO) Measures NIHTBPROUnadjSclScore Recommended CDE

 Change History

 Administrative Change History