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

 General Details

Title:
Neuro-QoL Pediatric Upper Extremity Function Short Form
Short Name:
NeuroQoLPedUpprExtrmtySF
Description:
NeuroQoL Pediatric Upper Extremity Function Short Form. Copyright 2008-2013 David Cella and the PROMIS Health Organization on behalf of the National Institute for Neurological Disorders and Stroke (NINDS)
Disease:
General (For all diseases) , Traumatic Brain Injury
Organization:
FITBIR
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-12-28
Owner:
Number of Data Elements:
41
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

NeuroQoL Form Administration (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life in Neurological Disorders (Neuro-Qol) - Form administered status  The specific Neuro-Qol form administered status, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLFormStatus Recommended CDE

Pediatric Upper Extremity Function SF (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life - Point finger ability scale  The scale which represents the extent to which the participant was able to use his or her finger to point to something, as part of Neuro-QOL Upper Extremity. QoLPointFingerAbilityScl Recommended CDE
2 Quality of Life - Take off sock ability scale  The scale which represents the extent to which the participant was able to take off his or her socks , as part of Neuro-QOL Upper Extremity. QoLTakeOffSockAbilityScl Recommended CDE
3 Quality of Life - Fasten pants ability scale  The scale which represents the extent to which the participant was able to put on and fasten his or her pants by his or herslef, as part of Neuro-QOL Upper Extremity. QoLFastenPantsAbilityScl Recommended CDE
4 Quality of Life - Button shirt ability scale  The scale which represents the extent to which the participant was able to button his or her own shirt, as part of Neuro-QOL Upper Extremity. QoLButtonShirtAbilityScl Recommended CDE
5 Quality of Life - Bring food mouth ability scale  The scale which represents the extent to which the participant was able to use a spoon to bring food up to his or her mouth, as part of Neuro-QOL Upper Extremity. QoLBringFoodMouthAbilityScl Recommended CDE
6 Quality of Life - Wipe ability scale  The scale which represents the extent to which the participant was able to wipe him or herslf thoroughly after using the toilet, as part of Neuro-QOL Upper Extremity. QoLWipeAbilityScl Recommended CDE
7 Quality of Life - Pull up pants ability scale  The scale which represents the extent to which the participant was able to pull his or her pants back up after using the toilet, as part of Neuro-QOL Upper Extremity. QoLPullUpPantsAbilityScl Recommended CDE
8 Quality of Life - Hold food plate ability scale  The scale which represents the extent to which the participant was able to hold a plate full of food, as part of Neuro-QOL Upper Extremity. QoLHoldFoodPlateAbilityScl Recommended CDE
9 Quality of Life - Cut paper ability scale  The scale which represents the extent to which the participant was able tot cut a piece of paper in half with scissors, as part of Neuro-QOL Upper Extremity. QoLCutPaperAbilityScl Recommended CDE
10 Quality of Life - Shower ability scale  The scale which represents the extent to which the participant was able to take a shower by him or herself, as part of Neuro-QOL Upper Extremity. QoLShowerAbilityScl Recommended CDE
11 Quality of Life - Bath ability scale  The scale which represents the extent to which the participant was able to take a bath by him or herself, as part of Neuro-QOL Upper Extremity. QoLBathAbilityScl Recommended CDE
12 Quality of Life - Key-pad phone call ability scale  The scale which represents the extent to which the participant was able to make a phone call using a touch tone key-pad, as part of Neuro-QOL Upper Extremity. QoLKeypadPhoneCallAbilityScl Recommended CDE
13 Quality of Life - Out bed ability scale  The scale which represents the extent to which the participant was able to get out of bed by him or herself, as part of Neuro-QOL Upper Extremity. QoLOutBedAbilityScl Recommended CDE
14 Quality of Life - Put on shoes ability scale  The scale which represents the extent to which the participant was able to put on my shoes by him or herself, as part of Neuro-QOL Upper Extremity. QoLPutOnShoesAbilityScl Recommended CDE
15 Quality of Life - Open jar ability scale  The scale which represents the extent to which the participant was able to open a jar by him or herself, as part of Neuro-QOL Upper Extremity. QoLOpenJarAbilityScl Recommended CDE
16 Quality of Life - Toothpaste toothbrush ability scale  The scale which represents the extent to which the participant was able to put toothpaste on a toothbrush by him or herself, as part of Neuro-QOL Upper Extremity. QoLToothpstToothbrshAbilityScl Recommended CDE
17 Quality of Life - Brush teeth ability scale  The scale which represents the extent to which the participant was able to brush his or her teeth by him or herself, as part of Neuro-QOL Upper Extremity. QoLBrushTeethAbilityScl Recommended CDE
18 Quality of Life - Dry back ability scale  The scale which represents the extent to which the participant was able to dry his or her back with a towel, as part of Neuro-QOL Upper Extremity. QoLDryBackAbilityScl Recommended CDE
19 Quality of Life - Clothe self ability scale  The scale which represents the extent to which the participant was able to put on his or her clothes by him or herself, as part of Neuro-QOL Upper Extremity. QoLClotheSelfAbiltyScl Recommended CDE
20 Quality of Life - Zip clothe ability scale  The scale which represents the extent to which the participant was able to zip up his or her clothes, as part of Neuro-QOL Upper Extremity. QoLZipClotheAbilityScl Recommended CDE

NeuroQol Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life in Neurological Disorders (Neuro-Qol) - Items completed count  The count of items on the Neuro-Qol form completed by the participant, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLItemCompletedCount Recommended CDE
2 Quality of Life in Neurological Disorders (Neuro-Qol) - Raw score  The participant's raw score on the Neuro-Qol form, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLRawScore Recommended CDE
3 Quality of Life in Neurological Disorders (Neuro-Qol) - Standard error  Standard error, as part of the Quality of Life in Neurological Disorders (Neuro-Qol) QoLStandardError Recommended CDE
4 Quality of Life in Neurological Disorders (Neuro-Qol) - T-score value  The value of the T-score, a standardized score with a mean of 50 and a standard deviation (SD) of 10 representing the rescaled raw score, as part of the Quality of Life in Neurological Disorders (Neuro-Qol).(PROMIS). QoLTScore Recommended CDE
5 Quality of Life in Neurological Disorders (Neuro-Qol) - Theta value  Theta metric value reported from the CAT Neuro-Qol results, as part of the Quality of Life in Neurological Disorders (Neuro-Qol). QoLThetaVal Recommended CDE

 Change History

 Administrative Change History