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

 General Details

Title:
Neuro-Qol Item Bank v1.0 - Participate in Social Roles and Activities
Short Name:
NeuroQolPartSocialRoleAct
Description:
This form contains the entire contents of the Neuro-QOL Item Bank v1.0 questions for Participating in Social Roles and Activities. This form can be used in it's entirety, or partly for the short form.
Disease:
Traumatic Brain Injury
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-11-03
Version:
1.0
Date Created:
2015-09-18
Owner:
Number of Data Elements:
63
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 Visit date   Actual interview or visit date VisitDate Recommended CDE
5 Site name   The name of the site for the study SiteName Recommended CDE
6 Case control indicator   Indicator of whether subject is in the case or control arm of the study CaseContrlInd Optional CDE
7 Days since baseline   The number of days since baseline DaysSinceBaseline Optional CDE
8 General notes text   General notes GeneralNotesTxt Optional CDE

Additional Element Groups

Listed below are your additional element groups.

Form Administration (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Context type  The context to which the questions were answered ContextType Recommended CDE
2 Context type other text  The free-text related to ContextType specifying other text ContextTypeOTH Recommended CDE
3 Data source  Source of the data provided on the case report form DataSource Recommended CDE
4 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

In the past 7 days (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Quality of Life - Family responsibility maintain past week scale  The scale representing how often the participant could keep up with their family responsibilities in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFamlyResponsbltyMaintainScl Recommended CDE
2 Quality of Life - Regular family activity ability past week scale  The scale representing how often the participant was able to do all of their regular family activities in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLRegulrFamilyActvityAbltyScl Recommended CDE
3 Quality of Life - Social interaction friend ability past week scale  The scale representing how often the participant was able to socialize with their friends in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLSocialInterctnFrndAbltyScl Recommended CDE
4 Quality of Life - Regular friend activity ability complete past week scale  The scale representing how often the participant was able to do all of their regular activities with friends in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLRegFrndActvtyAbltyCmplteScl Recommended CDE
5 Quality of Life - Social commitment maintain past week scale  The scale representing how often the participant was able to keep up with their social commitments in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLSocialCommitmentMaintainScl Recommended CDE
6 Quality of Life - Activity leisure participate past week scale  The scale representing how often the participant was able to participate in leisure activities in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLActvtyLeisurPartcptScl Recommended CDE
7 Quality of Life - Daily routine perform past week scale  The scale representing how often the participant was able to perform their daily routines in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLDailyRoutnPerformScl Recommended CDE
8 Quality of Life - Work responsibility maintain ability past week scale  The scale representing how often the participant could keep up with their work responsibilities (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWrkRspnsbltyMaintnAbltyScl Recommended CDE
9 Quality of Life - Family activity expectation complete past week scale  The scale representing how often the participant was able to do all of the family activities that people expected them to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFamActvtyExpctatnCompletScl Recommended CDE
10 Quality of Life - Family activity want complete past week scale  The scale representing how often the participant was able to do all of the family activities that they wanted to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFamilyActivtyWantComplScl Recommended CDE
11 Quality of Life - Friendship maintain past week scale  The scale representing how often the participant was able to maintain friendships as much as they would like in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFriendshipMaintainScl Recommended CDE
12 Quality of Life - Friend need satisfactory complete past week scale  The scale representing how often the participant could do everything for their friends that they wanted to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFriendNeedSatsfctryCmpltScl Recommended CDE
13 Quality of Life - Friend satisfy expectation activity ability past week scale  The scale representing how often the participant was able to do all of the activities with friends that people expected them to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFriendSatisfExpecAbilityScl Recommended CDE
14 Quality of Life - Friend activity satisfactory past week scale  The scale representing how often the participant was able to do all of the activities with friends that they wanted to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFriendActivitySatisfactScl Recommended CDE
15 Quality of Life - Regular leisure activity ability complete past week scale  The scale representing how often the participant was able to do all of their regular leisure activities in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLRegLesurActvtyAbltyCmpltScl Recommended CDE
16 Quality of Life - Hobby activity complete past week scale  The scale representing how often the participant was able to do their hobbies or leisure activities in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLHobbyActivityCompleteScl Recommended CDE
17 Quality of Life - Community activity want complete past week scale  The scale representing how often the participant was able to do all of the community activities that they wanted to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLCommActivityWantCompletScl Recommended CDE
18 Quality of Life - Leisure activity satisfactory complete past week scale  The scale representing how often the participant was able to do all of the leisure activities that people expect them to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLExpLeisrActvStsfctCmpltScl Recommended CDE
19 Quality of Life - Participant leisure activity satisfactory complete past week scale  The scale representing how often the participant could do all of the leisure activities that they wanted in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLLeisrActvtyStsfctryCmpltScl Recommended CDE
20 Quality of Life - Community activity ability complete past week scale  The scale representing how often the participant was able to do all of the community activities that people expect them to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLCommActivityAbilityComplScl Recommended CDE
21 Quality of Life - Outside home entertainment want satisfication past week scale  The scale representing how often the participant was able to go out for entertainment as much as they want in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLOutsdeEntrtnmntWntStfctnScl Recommended CDE
22 Quality of Life - No difficulty errand complete past week scale  The scale representing how often the participant was able to run errands without difficulty in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLNoDiffcultyErrndCompleteScl Recommended CDE
23 Quality of Life - Work usual abililty complete past week scale  The scale representing how often the participant was able to do all of their usual work (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkUsualAbilityCompleteScl Recommended CDE
24 Quality of Life - Work usual complete past week scale  The scale representing how often the participant was accomplishing as much as usual at work for them (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkUsualCompleteScl Recommended CDE
25 Quality of Life - Good work ability complete past week scale  The scale representing how often the participant's ability to do their work was as good as it could be (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLGoodWorkAbilityCompleteScl Recommended CDE
26 Quality of Life - Work everything ability past week scale  The scale representing how often the participant could do everything for work that they wanted do (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkEverythingAbilityScl Recommended CDE
27 Quality of Life - All work satisfactory complete past week scale  The scale representing how often the participant was able to do all of the work that people expected of them (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLAllWorkSatsfactryCmpletScl Recommended CDE
28 Quality of Life - Work usual ability past week scale  The scale representing how often the participant was able to do all of their usual work in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkUsualAbilityScl Recommended CDE
29 Quality of Life - Work satisfactory complete past week scale  The scale representing how often the participant was able to do all of the work that people expected them to do in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkSatisfactoryCompleteScl Recommended CDE
30 Quality of Life - Work shorter time period past week scale  The scale representing how often the participant had to do their work for shorter periods of time than usual for them in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkShorterTimePeriodScl Recommended CDE
31 Quality of Life - Family need satisfaction problem past week scale  The scale representing how often the participant had trouble meeting the needs of their family in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFamNeedSatisfactnProblemScl Recommended CDE
32 Quality of Life - Regular family activity limit ability past week scale  The scale representing how often the participant had to limit regular family activities in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLRegFamActivtyLimitAblityScl Recommended CDE
33 Quality of Life - Friend visit limit ability past week scale  The scale representing how often the participant felt limited in their ability to visit friends in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFriendVisitLimtAbilityScl Recommended CDE
34 Quality of Life - Friend visit limit time past week scale  The scale representing how often the participant felt limited in the amount of time they had to visit friends in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLFriendVisitLimitTimeScl Recommended CDE
35 Quality of Life - Home fun limit activity past week scale  The scale representing how often the participant had to limit the things they do for fun at home (like reading, listening to music, etc) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLHomeFunLimitActivityScl Recommended CDE
36 Quality of Life - Hobby leisure activity limit complete past week scale  The scale representing how often the participant had to limit their hobbies or leisure activities in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLHobbyLeisrActvtyLmtCmpltScl Recommended CDE
37 Quality of Life - Hobby leisure activity decrease time period past week scale  The scale representing how often the participant had to do their hobbies or leisure activities for shorter periods of time than usual for them in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLHbbyLeisrActvtyDecrseTmeScl Recommended CDE
38 Quality of Life - Social activity outside home limit complete past week scale  The scale representing how often the participant had to limit activities outside of their home in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLSocAcvtyOutsdHmeLmtCmpltScl Recommended CDE
39 Quality of Life - Social communication maintenance trouble past week scale  The scale representing how often the participant had trouble keeping in touch with others in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLSocCommnctnMaintnceTrblScl Recommended CDE
40 Quality of Life - Outside home entertainment limit ability past week scale  The scale representing how often the participant had to limit the things they do for fun outside their home in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLOutsdeHmEntrtnmtLmtAbltyScl Recommended CDE
41 Quality of Life - Group social activity decrease complete past week scale  The scale representing how often the participant did fewer social activities with groups of people than usual for them in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLGrpSocActvtyDecrsCompltScl Recommended CDE
42 Quality of Life - Regular chore trouble complete past week scale  The scale representing how often the participant had trouble doing their regular chores or tasks in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLReglrChoreTrbleCompleteScl Recommended CDE
43 Quality of Life - Work home limit complete past week scale  The scale representing how often the participant was limited in doing their work (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkHomeLimitCompleteScl Recommended CDE
44 Quality of Life - Work home decrease time period ability past week scale  The scale representing how often the participant had to do their work for shorter periods of time than usual for them (include work at home) in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWrkHmeDecreasTmeAbltyScl Recommended CDE
45 Quality of Life - Work limit complete past week scale  The scale representing how often the participant was limited in doing their work in the past 7 days, as part of Neuro-QOL Ability to Participate in SRA. QoLWorkLimitCompleteScl Recommended CDE

Scoring (Repeat Infinitely)

# 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
2 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
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) - 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
5 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
6 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

 Change History

 Administrative Change History