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

 General Details

Title:
NIH Toolbox Emotion Domain Peer Rejection Survey Parent Report Ages 3-12
Short Name:
NIHTBPeerRejectionPR3to12
Description:
As an analogue to the NIH Toolbox Perceived Rejection Survey, the NIH Toolbox Peer Rejection Survey is a parent-report measure for children ages 3-12. It is a 9-item fixed-length form that assesses how often a child is left out, avoided, or teased by peers. 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) , Traumatic Brain Injury
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-07-11
Owner:
Number of Data Elements:
40
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 Administration (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 administration language type  Type of language for test being administrated, as part of the NIH Toolbox NIHTBTestAdminLanguageTyp Recommended CDE
4 NIH Toolbox - Test administration language type other  Free-text related to NIHTBTestAdminLanguageTyp specifying other text, as part of the NIH Toolbox NIHTBTestAdminLanguageTypOTH Recommended CDE
5 NIH Toolbox - Test name type  Type of NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestNameTyp Recommended CDE
6 NIH Toolbox - Test name type other  The free-text related to NIHTBAdminTestNameTyp specifying other text, as part of the NIH Toolbox NIHTBAdminTestNameTypOTH 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 type  Type of flag for the NIH Toolbox test being administered, as part of the NIH Toolbox NIHTBAdminTestFlagTyp Recommended CDE
9 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

NIH Toolbox Peer Rejection Survey PR Ages 3-12 (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Left out scale  Scale for the parent reported statement: How often your child is left out by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12LeftOutScl Recommended CDE
2 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Refuse play scale  Scale for the parent reported statement How often other children refuse to let your child play with them, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12RefusePlyScl Recommended CDE
3 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Playmate scale  Scale for the parent reported statement How often your child is not chosen as a playmate, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12PlaymateScl Recommended CDE
4 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Rejected scale  Scale for the parent reported statement How often your child is actively rejected by other children who refuse to play with him/her, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12RejectedScl Recommended CDE
5 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Avoided scale  Scale for the parent reported statement How often your child is avoided by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12AvoidedScl Recommended CDE
6 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Liked scale  Scale for the parent reported statement How often your child is not well liked by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12LikedScl Recommended CDE
7 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Picked on scale  Scale for the parent reported statement How often your child is picked on, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12PickedOnScl Recommended CDE
8 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Teased scale  Scale for the parent reported statement How often your child is teased and made fun of by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12TeasedScl Recommended CDE
9 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Pushed scale  Scale for the parent reported statement How often your child is pushed or shoved around by other children, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12PushedScl Recommended CDE

NIH Toolbox Peer Rejection Survey Prt Rpt 3-12 Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Raw score  Raw score, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12RawScore Recommended CDE
2 NIH Toolbox Emotion Peer Rejection Parent Report 3-12 - Theta score  Theta score, for ages 3-12, as part of the NIH Toolbox Emotion Battery Peer Rejection Parent Report Fixed Form. NIHTBPRPRFF3to12ThetaScore 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
7 NIH Toolbox - Standard error  Standard error (a statistical measure of variance that represents the margin of error for the Tscore), as part of the NIH Toolbox NIHTBStandardError Optional CDE

 Change History

 Administrative Change History