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

 General Details

Title:
Neuro-QoL Upper Extremity Function Short Form
Short Name:
NeuroQoLUppExtrmtySF
Description:
NeuroQoL 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:
2016-12-29
Owner:
Number of Data Elements:
29
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

Upper Extremity SF (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life - Movement turn key lock ability scale  The scale which represents the extent to which the participant was able to turn a key in a lock, as part of Neuro-QOL Upper Extremity. QoLMoveTurnKeyLockAbilityScl Recommended CDE
2 Quality of Life - Movement brush teeth ability scale  The scale which represents the extent to which the participant was able to brush their teeth, as part of Neuro-QOL Upper Extremity. QoLMoveBrushTeethAblityScl Recommended CDE
3 Quality of Life - Movement touch-tone 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. QolMoveTouchTneCallAbilityScl Recommended CDE
4 Quality of Life - Movement pick up coin ability scale  The scale which represents the extent to which the participant was able to pick up coins from a table top, as part of Neuro-QOL Upper Extremity. QoLMovePckUpCoinAbltyScl Recommended CDE
5 Quality of Life - Movement pen pencil write ability scale  The scale which represents the extent to which the participant was able to write with a pen or pencil, as part of Neuro-QOL Upper Extremity. QolMovePenPenclWrteAbilityScl Recommended CDE
6 Quality of Life - Movement zipper open close ability scale  The scale which represents the extent to which the participant was able to open and close a zipper, as part of Neuro-QOL Upper Extremity. QoLMoveZipprOpnClseAblityScl Recommended CDE
7 Quality of Life - Movement body wash dry ability scale  The scale which represents the extent to which the participant was able to wash and dry their body, as part of Neuro-QOL Upper Extremity. QoLMoveBodyWashDryAblityScl Recommended CDE
8 Quality of Life - Movement shampoo hair ability scale  The scale which represents the extent to which the participant was able to shampoo their hair, as part of Neuro-QOL Upper Extremity. QoLMoveShampooHairAbilityScl 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