This form structure is an organized set of data definitions for a form that has not been copyrighted

 General Details

Title:
Ohio State University TBI Identification Method Interview Form (OSUTBIMI)
Short Name:
OSUTBIMI
Description:
The Ohio State University (OSU) Traumatic Brain Injury (TBI) Identification Method (OSU TBI-ID) is a standardized procedure for eliciting a person’s lifetime history of TBI via a 3-5 minute structured interview. While not ideal for determining lifetime exposure to potentially damaging brain injury, self-report remains the gold standard for research and clinical use. The OSU TBI-ID has proven useful in many settings, including medical, mental health, substance abuse, domestic violence, corrections and aging. Health care and social service professionals need this tool to elicit a person’s history of TBI. References: http://ohiovalley.org/tbi-id-method/clinical/ Form: https://osuwmcdigital.osu.edu/sitetool/sites/ohiovalleypublic/documents/OSU_TBIform_July2013.pdf
Disease:
Traumatic Brain Injury
Organization:
NIH
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2017-04-24
Version:
1.0
Date Created:
2016-03-18
Owner:
Number of Data Elements:
43
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

Step 1 (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever hospitalized after a head or neck injury indicator  Indicator of the subject ever being hospitalized or treated in an emergency room following an injury to their head or neck, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIEverHospAftrHeadInjInd Recommended UDE
2 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever injured head or neck in a crash indicator  Indicator of the subject ever injuring their head or neck in a car accident or from crashing some other moving vehicle, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIEverInjHeadInCrashInd Recommended UDE
3 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever injured head or neck in a fall or getting hit indicator  Indicator of the subject ever injuring their head or neck in a fall or from being hit by something, or from playing sports or on the playground, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIEverInjHeadFallHitInd Recommended UDE
4 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever injured head or neck in a fight indicator  Indicator of the subject ever injuring their head or neck in a fight, from being hit, from being shaken violently, or from being shot in the head, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIEverInjHeadInFightInd Recommended UDE
5 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Ever been near an explosion indicator  Indicator of the subject ever being nearby when an explosion or a blast occurred, in their lifetime, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIEverNearExplosnInd Recommended CDE

Step 2 (Appears Up To 22 Times)

# Title Short Description Variable Name Required? Type
1 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Hospitalized after a head or neck injury cause  Cause of the subject ever being hospitalized or treated in an emergency room following an injury to their head or neck, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIHospAftrHeadInjCause Recommended UDE
2 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injured head or neck in a crash cause  Cause of the subject ever injuring their head or neck in a car accident or from crashing some other moving vehicle, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIInjHeadInCrashCause Recommended UDE
3 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injured head or neck in a fall or getting hit cause  Cause of the subject ever injuring their head or neck in a fall or from being hit by something, or from playing sports or on the playground, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIInjHeadFallHitCause Recommended UDE
4 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injured head or neck in a fight cause  Cause of the subject ever injuring their head or neck in a fight, from being hit, from being shaken violently, or from being shot in the head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIInjHeadInFightCause Recommended UDE
5 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Near an explosion cause  Cause of the subject ever being nearby when an explosion or a blast occurred, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMINearExplosnCause Recommended CDE
6 Loss of consciousness indicator  The indicator for whether the participant/subject experienced any period of loss of consciousness (LOC). LOCInd Recommended CDE
7 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Loss of consciousness duration range  The range of duration of loss of consciousness the participant/subject experienced, as part of Ohio State University TBI Identification Method Interview Form (OSUTBIMI). OSUTBIMILOCDurRang Recommended UDE
8 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Dazed or memory gap from injury indicator  Indicator of the subject being dazed or having a gap in their memory from the injury, if they did not lose consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIDazedMemoryGapInjInd Recommended UDE
9 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Loss of consciousness from injury age  Age of subject when they were knocked out, lost consciousness, dazed, or had gaps in their memory from the injury, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMILOCAge Recommended UDE

Step 3 (Appears Up To 13 Times)

# Title Short Description Variable Name Required? Type
1 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Repeated head impacts indicator  Indicator of the subject ever having a period of time in which they experienced multiple, repeated impacts to their head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIRepeatHeadImpactInd Recommended UDE
2 Ohio State TBI Method Short Form (OSUTBIMS) - cause reason  The cause of the subject's injury as part of Ohio State TBI Method Short Form (OSUTBIMS). OSUTBIMSCauseRsn Recommended CDE
3 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Typical effect of repeated head injuries type  Type typical or usual effect of multiple, repeated impacts to the subject's head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMITypicalEffectInjTyp Recommended UDE
4 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Dazed or memory gap from repeated head injuries indicator  Indicator of the subject being dazed or having a gap in their memory from the multiple, repeated impacts to their head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIDazeMemGapRepeatInjInd Recommended UDE
5 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Most severe effect from head injury type  Type of most severe effect from one of the time the subject had an impact to the head, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMISevereEffectInjTyp Recommended UDE
6 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Repeated head injuries began age  Age of subject when repeated injuries began, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIRepeatHeadInjStartAge Recommended UDE
7 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Repeated head injuries ended age  Age of subject when repeated injuries ended, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIRepeatHeadInjEndAge Recommended UDE
8 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Additional injuries with loss of consciousness number  Number of additional injuries with loss of consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIAdditionalInjLOCNum Recommended UDE
9 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Knocked out longest duration  Longest duration of being knocked out during additional injuries with loss of consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIKnockOutLongestDur Recommended UDE
10 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injuries with loss of consciousness ? 30 minutes number  Number of additional injuries with loss of consciousness that lasted 30 minutes or more, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIInjLOC30PlusMinNum Recommended UDE
11 Ohio State University TBI Identification Method Interview Form (OSUTBIMI) - Injuries with loss of consciousness youngest age  Youngest age subject had additional injuries with loss of consciousness, as part of the Ohio State University TBI Identification Method Interview Form (OSUTBIMI) OSUTBIMIInjLOCYoungestAge Recommended UDE

Worst injury (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Traumatic event number  The number of traumatic event , which happened during the subject's life, as reported by the subject TraumaticEventNum Recommended CDE
2 Ohio State TBI Method Short Form (OSUTBIMS) - worst injury result  Result to whether the subject has: 1 an \"improbable TBI\", 2 a \"possible TBI\", 3 a \"mild TBI\", 4 a \"moderate TBI\", or 5 a \"severe TBI\" as part of Ohio State TBI Method Short Form (OSUTBIMS) OSUTBIMSWorstInjReslt Recommended CDE
3 Ohio State TBI Method Short Form (OSUTBIMS) - cause reason  The cause of the subject's injury as part of Ohio State TBI Method Short Form (OSUTBIMS). OSUTBIMSCauseRsn Recommended CDE

 Change History

 Administrative Change History