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

 General Details

Title:
Neuro-QoL Pediatric Lower Extremity Function Short Form
Short Name:
NeuroQolPedLwrExtrmtySF
Description:
NeuroQoL Pediatric Lower 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:
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

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

# Title Short Description Variable Name Required? Type
1 Quality of Life - Kneel without hold scale  The scale which represents the extent to which the participant could get down on his or her knees without holding on to something, as part of Neuro-QOL Lower Extremity Function. QoLKneelWithoutHoldScl Recommended CDE
2 Quality of Life - Keep up scale  The scale which represents the extent to which the participant could keep up when he or she played with other kids, as part of Neuro-QOL Lower Extremity Function. QoLKeepUpScl Recommended CDE
3 Quality of Life - Walk 15 minute scale  The scale which represents the extent to which the participant could walk for 15 minutes, as part of Neuro-QOL Lower Extremity Function. QoLWalkFifteenMinuteScl Recommended CDE
4 Quality of Life - Walk between room scale  The scale which represents the extent to which the participant could walk between rooms, as part of Neuro-QOL Lower Extremity Function. QoLWalkBetweenRoomScl Recommended CDE
5 Quality of Life - Toilet on off scale  The scale which represents the extent to which the participant could get on and off the toilet without using his or her arms, as part of Neuro-QOL Lower Extremity Function. QoLToiletOnOffScl Recommended CDE
6 Quality of Life - Chair on off scale  The scale which represents the extent to which the participant could get on and off a low chair, as part of Neuro-QOL Lower Extremity Function. QoLChairOnOffScl Recommended CDE
7 Quality of Life - Floor up scale  The scale which represents the extent to which the participant could get up from the floor by myself, as part of Neuro-QOL Lower Extremity Function. QoLFloorUpScl Recommended CDE
8 Quality of Life - Bench without support scale  The scale which represents the extent to which the participant could sit on a bench without support for 15 minutes, as part of Neuro-QOL Lower Extremity Function. QoLBenchWithoutSupportScl Recommended CDE
9 Quality of Life - Tiptoes reach scale  The scale which represents the extent to which the participant could stand on my tiptoes to reach for something, as part of Neuro-QOL Lower Extremity Function. QoLTiptoesReachScl Recommended CDE
10 Quality of Life - Tiptoes place scale  The scale which represents the extent to which the participant could stand on my tiptoes to put something (e.g., 5 lb bag of sugar) on a shelf, as part of Neuro-QOL Lower Extremity Function. QoLTipotoesPlaceScl Recommended CDE
11 Quality of Life - Walk slight uneven scale  The scale which represents the extent to which the participant could walk on slightly uneven surfaces (such as cracked pavement), as part of Neuro-QOL Lower Extremity Function. QoLWalkSlightUnevenScl Recommended CDE
12 Quality of Life - Walk rough uneven scale  The scale which represents the extent to which the participant could walk on rough, uneven surfaces (such as lawns, gravel driveway), as part of Neuro-QOL Lower Extremity Function. QoLWalkRoughUnevenScl Recommended CDE
13 Quality of Life - Ramp up down scale  The scale which represents the extent to which the participant could walk up and down ramps or hills, as part of Neuro-QOL Lower Extremity Function. QoLRampUpDownScl Recommended CDE
14 Quality of Life - Curb up down scale  The scale which represents the extent to which the participant could walk up and down curbs, as part of Neuro-QOL Lower Extremity Function. QoLCurbUpDownScl Recommended CDE
15 Quality of Life - Bus in out scale  The scale which represents the extent to which the participant could get in and out of a bus, as part of Neuro-QOL Lower Extremity Function. QoLBusInOutScl Recommended CDE
16 Quality of Life - Car in out scale  The scale which represents the extent to which the participant could get in and out of a car, as part of Neuro-QOL Lower Extremity Function. QoLCarInOutScl Recommended CDE
17 Quality of Life - Walk across room scale  The scale which represents the extent to which the participant could walk across the room, as part of Neuro-QOL Lower Extremity Function. QoLWalkAcrossRoomScl Recommended CDE
18 Quality of Life - Backpack walk scale  The scale which represents the extent to which the participant could walk while wearing a backpack full of books, as part of Neuro-QOL Lower Extremity Function. QoLBackpackWalkScl Recommended CDE
19 Quality of Life - Bend over scale  The scale which represents the extent to which the participant could bend over to pick something up, as part of Neuro-QOL Lower Extremity Function. QoLBendOvrScl Recommended CDE
20 Quality of Life - Exercise peers scale  The scale which represents the extent to which the participant could do exercise that others my age can do, as part of Neuro-QOL Lower Extremity Function. QoLExercisePeersScl 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