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 13y-18y (PCSI-SR13)
Short Name:
PCSISR13
Description:
The adolescent self-report form (PCSI-SR13) ages 13 to 18yrs contains 21 items, and responses were rated for severity on the 7-point Guttman dimensional scale. The following anchors were provided: 0 = Not a problem, 3 = Moderate problem, 6 = Severe problem. 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
Publication Date:
2018-03-13
Version:
1.1
Date Created:
2016-05-03
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 2 Times)

# 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 13-18yrs (PCSISR13) (Appears Up To 2 Times)

# Title Short Description Variable Name Required? Type
1 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Headache scale  Scale to which the subject complained of headaches, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13HeadacheScl Recommended CDE
2 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Nausea scale  Scale to which the subject complained of nausea, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13NauseaScl Recommended CDE
3 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Balance problem scale  Scale to which the subject experienced balance problems, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13BalanceProbScl Recommended CDE
4 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Dizziness scale  Scale to which the subject appeared or complained of dizziness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13DizzinessScl Recommended CDE
5 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Fatigue scale  Scale to which the subject has fatigue, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13FatigueScl Recommended CDE
6 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sleep more than usual scale  Scale to which the subject slept more than usual, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13SleepMoreThnUsualScl Recommended CDE
7 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Drowsiness scale  Scale to which the subject experiences drowsiness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13DrowsinessScl Recommended CDE
8 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sensitive to light scale  Scale to which the subject was sensitive to light, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13SensitiveToLightScl Recommended CDE
9 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sensitive to noise scale  Scale to which the subject was sensitive to noise, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13SensitiveToNoiseScl Recommended CDE
10 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Irritability scale  Scale to which the subject expressed irritability, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13IrritabilityScl Recommended CDE
11 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Sadness scale  Scale to which the subject expressed sadness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13SadnessScl Recommended CDE
12 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Nervousness scale  Scale to which the subject expressed nervousness, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13NervousnessScl Recommended CDE
13 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Feeling more emotional scale  Scale to which the subject was feeling more emotional, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13FeelMoreEmotionalScl Recommended CDE
14 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Feeling slowed down scale  Scale to which the subject was feeling slowed down, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13FeelSlowedDownScl Recommended CDE
15 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Feeling mentally foggy scale  Scale to which the subject was feeling mentally foggy, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13MentallyFoggyScl Recommended CDE
16 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Difficulty concentrating scale  Scale to which the subject had difficulty concentrating, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13DiffConcentrateScl Recommended CDE
17 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Difficult remembering scale  Scale to which the subject had difficulty remembering, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13DiffRememberScl Recommended CDE
18 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Visual problems scale  Scale to which the subject expressed visual problems (blurry, double vision), as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13VisualProbScl Recommended CDE
19 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Get confused with directions or tasks scale  Scale to which the subject expressed getting confused with directions or tasks, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13ConfuWthDirctnsScl Recommended CDE
20 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Clumsy scale  Scale to which the subject appeared to move in a clumsy manner, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13ClumsyScl Recommended CDE
21 Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13) - Answer slowly scale  Scale to which the subject answered questions more slowly than usual, as part of the Post-Concussion Symptom Inventory - Self Report 13y-18y (PCSI-SR13). PCSISR13AnswSlowlyScl 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