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

 General Details

Title:
Post-Concussion Symptom Inventory - Self Report 5y-7y and 8y-12y(PCSI-SR)
Short Name:
PCSISR
Description:
The older child self-report form for ages 8 to12 years (PCSI-SR8) contains 17 items, and responses were simplified and rated for severity to a 3-point Guttman scale (0 = No, 1 = A little, 2 = A lot). The younger child self-report form for ages 5 to 7 years (PCSI-SR5) contains 5 items, and responses were simplified and rated for severity to a 3-point Guttman scale (0 = No, 1 = A little, 2 = A lot). References: Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, https://www.ncbi.nlm.nih.gov/books/NBK185341/ Recommended by CDISC for TBI (TAUG TBI)
Disease:
Traumatic Brain Injury
Organization:
NIH/CIT/DCB
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-05-03
Owner:
Number of Data Elements:
42
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 (Repeat Infinitely)

# 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

PCSI Self Report 8y-12y (PCSISR8) (Appears Up To 2 Times)

# Title Short Description Variable Name Required? Type
1 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Headache scale  Scale to which the subject complained of having headaches or head hurting, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRHeadacheScale Recommended CDE
2 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Sick in stomach/Nausea scale  Scale to which the subject complained of feeling sick to their stomach or being nauseaous, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltSickStomachScale Recommended CDE
3 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Balance problem scale  Scale to which the subject experienced balance problems, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRBalanceProbScale Recommended CDE
4 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt dizzy scale  Scale to which the subject has felt dizzy, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltDizzyScale Recommended CDE
5 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - More Tired Than Usual scale  Scale to which the subject has felt more tired than usual, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRMoreTiredThanUsualScale Recommended CDE
6 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt more drowsy or sleepy than usual scale  Scale to which the subject has felt more drowsy or sleepy than usual, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltDrowsySleepyScale Recommended CDE
7 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Bright light bother more than usual scale  Scale to which the subject expressed that bright lights have bothered them more than usual, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRBrightLightBotherScale Recommended CDE
8 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Loud noises bother scale  Scale to which the subject was sensitive to noise, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRLoudNoiseBotherScale Recommended CDE
9 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt grumpy or irritability scale  Scale to which the subject felt grumpy or irritable, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltGrumpyScale Recommended CDE
10 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt sad scale  Scale to which the subject has felt sad, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltSadScale Recommended CDE
11 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt nervous or worried scale  Scale to which the subject has felt nervous or worried, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltNervousWorriedScale Recommended CDE
12 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt like moving more slowly scale  Scale to which the subject was feeling like they were moving more slowly, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRMovingMoreSlowlyScale Recommended CDE
13 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Thinking more slowly scale  Scale to which the subject felt that they were thinking more slowly, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRThinkMoreSlowScale Recommended CDE
14 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to think clear scale  Scale to which the subject felt that it has been hard to think, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRHardThinkClearScale Recommended CDE
15 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to pay attention scale  Scale to which the subject expressed that it has been hard for them to pay attention to what they are doing, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRHardPayAttentionScale Recommended CDE
16 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to remember things scale  Scale to which the subject has found it hard to remember things, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRHardRememberThingsScale Recommended CDE
17 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Things look blurry scale  Scale to which the subject expressed that things looked blurry, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRLookBlurryScale Recommended CDE

PCSI Self Report 5y-7y (PCSISR5) (Appears Up To 2 Times)

# Title Short Description Variable Name Required? Type
1 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Headache scale  Scale to which the subject complained of having headaches or head hurting, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRHeadacheScale Recommended CDE
2 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Sick in stomach/Nausea scale  Scale to which the subject complained of feeling sick to their stomach or being nauseaous, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltSickStomachScale Recommended CDE
3 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt dizzy scale  Scale to which the subject has felt dizzy, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltDizzyScale Recommended CDE
4 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Felt grumpy or irritability scale  Scale to which the subject felt grumpy or irritable, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRFeltGrumpyScale Recommended CDE
5 Post-Concussion Symptom Inventory - Self Report (PCSI-SR) - Hard to pay attention scale  Scale to which the subject expressed that it has been hard for them to pay attention to what they are doing, as part of the Post-Concussion Symptom Inventory - Self Report (PCSI-SR). PCSISRHardPayAttentionScale Recommended CDE

PCSI Scoring (Appears Up To 2 Times)

# Title Short Description Variable Name Required? Type
1 Post-Concussion Symptom Inventory - Physical Factor Subscale Summary Score  Score of the Physical Content-based factors, as a part of the Post-Concussion Symptom Inventory PCSI PCSIPhysicalSymptomSubsclScore Recommended CDE
2 Post-Concussion Symptom Inventory - Cognitive Factor Subscale Summary Score  Score of the Cognitive Content-based factor subscale, as a part of the Post-Concussion Symptom Inventory PCSI PCSICognitiveSymptmSubsclScore Recommended CDE
3 Post-Concussion Symptom Inventory - Emotional Factor Subscale Summary Score  Score of the Emotional Content-based factor subscale, as a part of the Post-Concussion Symptom Inventory PCSI PCSIEmotionalSymptmSubsclScore Recommended CDE
4 Post-Concussion Symptom Inventory - Fatigue Factor Subscale Summary Score  Score of the Fatigue Content-based factor subscale, as a part of the Post-Concussion Symptom Inventory PCSI PCSIFatigueSymptomSubsclScore Recommended CDE
5 Post-Concussion Symptom Inventory - Total Score  Total score, as a part of the Post-Concussion Symptom Inventory PCSI PCSITotalScore Recommended CDE

 Change History

 Administrative Change History