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

 General Details

Title:
Neuro-QoL Upper Extremity Function Long Form
Short Name:
NeuroQoLUpprExtmtyFunctnLF
Description:
NeuroQoL Upper Extremity Function Long Form. Copyright 2008-2013 David Cella and the PROMIS Health Organization on behalf of the National Institute for Neurological Disorders and Stroke (NINDS)
Disease:
Traumatic Brain Injury , General (For all diseases)
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

Upper Extremity Function LF (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
9 Quality of Life - Movement open prior open jar ability scale  The scale which represents the extent to which the participant was able to open previously opened jars, as part of Neuro-QOL Upper Extremity. QolMoveOpnPriorOpnJarAbltyScl Recommended CDE
10 Quality of Life - Movement full food plate hold 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. QolMoveFulFoodPlatHldAbltyScl Recommended CDE
11 Quality of Life - Movement pull trouser on ability scale  The scale which represents the extent to which the participant was able to pull on trousers, as part of Neuro-QOL Upper Extremity. QolMovePullTrouserOnAbiltyScl Recommended CDE
12 Quality of Life - Movement button shirt ability scale  The scale which represents the extent to which the participant was able to button their shirt, as part of Neuro-QOL Upper Extremity. QolMoveButtonShirtAblityScl Recommended CDE
13 Quality of Life - Movement fingernail trim ability scale  The scale which represents the extent to which the participant was able to trim their fingernails, as part of Neuro-QOL Upper Extremity. QolMoveFingernlTrimAbiltyScl Recommended CDE
14 Quality of Life - Movement toenail trim ability scale  The scale which represents the extent to which the participant was able to cut their toe nails, as part of Neuro-QOL Upper Extremity. QolMoveToenailTrimAbiltyScl Recommended CDE
15 Quality of Life - Movement bend down pick up cloth ability scale  The scale which represents the extent to which the participant was able to bend down and pick up clothing from the floor Neuro-QOL Upper Extremity. QoLMoveBndDwnPckUpClthAbltyScl Recommended CDE
16 Quality of Life - Movement spoon eat meal difficulty scale  The scale which represents the amount of difficulty the participant currently has in using a spoon to eat a meal, as part of Neuro-QOL Upper Extremity. QolMoveSpoonEatMealAbilityScl Recommended CDE
17 Quality of Life - Movement dress pullover shirt on difficulty scale  The scale which represents the amount of difficulty the participant currently has in putting on a pullover shirt, as part of Neuro-QOL Upper Extremity. QolMoveDrssPllvrShrtAblityScl Recommended CDE
18 Quality of Life - Movement dress pullover shirt off difficulty scale  The scale which represents the amount of difficulty the participant currently has in taking off a pullover shirt, as part of Neuro-QOL Upper Extremity. QoLMoveDrssPllovrOffAbilityScl Recommended CDE
19 Quality of Life - Movement small object remove wrap difficulty scale  The scale which represents the amount of difficulty the participant currently has in removing wrappings from small objects, as part of Neuro-QOL Upper Extremity. QoLMoveSmllObjtRmvWrpAblityScl Recommended CDE
20 Quality of Life - Movement medication open difficulty scale  The scale which represents the amount of difficulty the participant currently has in opening medications or vitamin containers (e.g., childproof containers, small bottles) as part of Neuro-QOL Upper Extremity. QolMoveMedicatnOpnAbiltyScl 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